Comprehensive Counseling for Reproductive Health - USAID

ComprehensiveCounseling for

Reproductive Health:An Integrated

Curriculum

Trainers'Manual

•ENGENDERHEALTHImpro~ing Women's HealTh World..,ide

/

© 2003 EngenderHealth. All rights reserved.

440 Ninth Avenue

New York, NY 10001 U.S.A.

Telephone: 212-561-8000

Fax: 212-561~8067

e-mail: [email protected]

www.engenderhealth.org

This publication was made possible, in part, through support pro"ided by

the Office of Populatic.'TI, U.S. Agency for International Development (AID),

under the terms of cooperative agreement HRN-A-OO-9S-00042-1l0. The

opinions expressed herein are those of the publisher and do not II eu:ssari Iy

reflect the views of AID.

Cover design: Virginia Taddoni

Cover photo credits: United Nations; Jean Ahlborg; United Nations: John Isaac

Printed in the United States of l\merica. Printed on recycled pape!

Library of Congress CataJoging·in.Publication Data

Comprehensive counseling for reproductive health. Trainers' nwnual : an integrated approach.

p. ;cm.ISBN 1-885063-39-3

1. Hygiene, Sexual--Study and teaching--Handbooks. manuals. etc. 2. Reproductive health

--Study and teaching--Handbooks, manuals, etc. 3. Birth conto I clinics~-Employees--Training

of--Handbooks, manuals, etc. 4. Sex counseling-Study and h~aching-Handbooks, manuals,

etc. 5. Curriculum planning~-Handbooks,manuals, etc. L EngenderHealth (Finn)

[DNLM: 1. Sex Counseling. 2. Family Planning. 3. Teaching Materials. WM 18.2 C7372

2003]RA788 .C6515 2003

613.9'071'1 ~-dc212003048772

/'

//

Contents

Preface

Acknowledgment<;

Introduction for the Trainers ... "

\

\ II

\1

Part I: Principles and Approaches for Client-Centered Communicationin Sexual and Reproductive Health .. "

Session I: We Icome and Introduction .... " .. "".""" ...

Session 2: Dcfil1lng Scxual and Reprodlh.:ti\t· Health ami Inte~r~lleJ

SRH Coun"eling .. . . .. .. . .... " .

Session 3: Why ..\ddres' Se\.llalit~·) ..

Sessi0n -+: The Problem TrIC'C- R\)l '£-. and Cl)Tb'-'ljlJClkL" l)f SRII Prc,I'k';n,

Session 5: Supporting Clients" Informed and Voluntary DCL'j"il'n \Ltl-.:ill~ "

Se"sinn 6: Clicnt Pwllk.' fl)r SC\lhd and RCprL)dudi\e He,dthDecision .\1aking " ..

Session 7: Clients' RighI<" Cllent-Pro\ldL'r Intt'raction. and Cpunscllni.=

Session 8: Counseling FrameworksOption .\ REDl " .

Option B: G.-\THER "

11

15

Part II: The Role of Providers' Attitudes in Creating a Good Climate for Communication

Session 9: Rapport-Building--Respccl. Prai'c. and Ellcnur~lgemt'nt

Session 10: Pro\ider Behefs and Attitude.'

Session 1I: Se\.Ualit\

A. Rctlt:ctlOn, on How \Ve LearneJ ahoLlt Se'\uality

B Aspects of Sexualit:-

C. Se\.ual and SOCial Dt'\'clopmcnt .

Session 12: Variation, In Sexual Beha\iur " ..

Session 13: BUIlding Rapport with \lak Chents anJ withAdolescent Clients " .

Part III: Communication Skills ..

Session 1-+: Asking Open-Ended Questions

Session 15: Listening and ParaphraslIlg ... "

Session 16: Using Language Tha[ ClienL~ Can l-ndeNanJ

Session 17: Using Visual Aids [0 Explain Rcprooucti\'eAnatomy and Physiolog::- .

, '-+ -'

t-l

~I

SI

91

EngenderHealth Comprehensive Counseling for Reproduc~lve Heal~"t-Trainers" Manual iii

Part IV: Helping Clients Assess Their Comprehensive SRH ~eeds and ProvidingAppropriate Information . . . . . . . . . . . . . . . . . . . .. 95

Session 18: Introducing the Subject of Sexuality with Clients . . . . . . . . . . . . . . . . . . . .. 97

Session 19: The Risk Continuum _ _ 101

Session 20: Exploring the Context of Clients' Sexual Relationships 109

Session 21: Infonnation-Giving in Integrated SRH Counseling 115

Session 22: Risk Assessment-Improving Clients' Perception of Risk . . . . . . . . . . . .. 121

Session 23: Counseling Practice I . . . . . . . . . . . . . . . . . . . .. . 125

Part V: Assisting Clients in Making Their Own Voluntary and Informed Decisions 129

Session 24: Gender Roles . . .. . . . . . . . . . . . . . . . . . . . . .. 131

Session 25: The Effect of Power Imbalances on SRI-l Decision \;Taking 133

Session 26: Helping Clients ;vlake Decisions-Counseling F'J:lCtice II 139

Part VI: Helping Clients Develop the Skills to Carry Out Their Decisions 145

Session 27: Helping Clients Develop an Implementation Plan--Counse1ing Practice III 147

Session 28: Helping Clients Develop Skills in Partner Communication and Negotiation 153

Part VII: Final Steps in Implementing Integrated SRH Counseling 157

Session 29: Counseling Practice--Final _ 159

Session 30: Meeting Providers' Needs and Overcoming Barri'T' to OfferingIntegrated SRH Counseling . . . . . . . . . . . . . . . . . . . . . .. 163

Session 31: Individual Plans for Applying What Was Learned in This Training 169

Session 32: Training Follow-Up 171

Session 33: Workshop Evaluation and Closing. . . . . . . . . . . . 173

Appendixes

Appendix A: Sample Training Agendas _ 175

Appendix B: Daily Warm-Ups and Daily Wrap-Ups .. . 183

Appendix C: Promoting Informed and Voluntary DeciSion M8king to SupportClients' Rights and Address Clients' Needs __ _. .. 191

Appendix D: Participants' Self-Assessment of Knowledge and Attitudes:

PretestlPosttest __ . . . . . . . . . . . . . . . . .. 231

Appendix E: Participant Evaluation Form _ , 245

Appendix F: Trainer Evaluation Form . 251

Appendix G: Outcome Evaluation Using Observation of Client-Provider Interactions 257

Appendix H: Outcome Evaluation Using Provider Interviews 269

Appendix I: Outcome Evaluation Using Client Interviews .. . 285

Appendix J: Using Visual Aids to Explain Reproductive Anatomy and

Physiology-Transparency Guides _. . . . . . .. . 293

iv Comprehensive Counseling for Reproductive Health-Trainers' Manual EngenderHeallh

Preface

Since the International Conference on Population and Dne lopment. held in Cairo in 199.1,

and the Fourth World Conference on Women. held in Beijlt1~ in 1995. the intcrnatl(lnal d,,\e1~

opment and public health communities have embraced a more comprehen"i\e reprl1ductivt'

health agenda and ha\'e sought to provide an ex.panded range of sen·ice.; in J. more mtegrated

fashion. This shift to integrated reproducti\'c health has included heightened attention to the

rights of clients. the quality of care. informed chOICe. and gender sensitivit~.

Equally important. the shift has brought increased recognition of clicnh' hroad. interrelated

sexual and reproductive health needs and of the changes reqUired throughout thc health care

system to meet them. If service programs arc to :--CilC all llpportllnnic:-- tll llknLIf~ and mect

clients' reproductive health needs more holistically. they must take a client-L"entercli aprfl)~lCb.

link services so as to offer comprehensive care that (l'\"Cr" client'" interreLHed need..:. ..lnd

ensure that their providers are sensitive to medical. bckl\·ioral. and "oclal i:--:--ue" tlut may

underlie the cxpres..;ed reasons for the client's \"i"it.

Pro\"iders require training and institutional support to dcwl0p the :--kills. knowleJ::c. and com

fort they need to communicate cffecti\"ely with their dicnh about health Ldre thaI rdate.; tl) the

function of reproduction. the anatomy that support.;, that function. and the beha\"ior" rebted II.'

se:"uality and reproduction. This includc'>. for e\~lIllpk. family pbnnin~. m.ltcrn;l! hc.dth. <,\.

ually transmitted infections. and related sexual practice:--. All of these :--e[\l.:e, ~tll.:i :--Ulo\CI..'I,

share certain characteristics that make them particularly scn'iti\"e: They are lOten:--dy pt?r":'I.'n,tl

and command a high degree of pri\acy: they are ~bsociated with ,>trongly held hcliefs: and

they are the subject of social. religious. political. andlcgal -.rricture:--. :\11 a)..,o arc 'lgDltl(J.ntl~

affected by sexual partners and beha\·iors. which hear directly on an wdi\"iJual"..:. ..:hl.'I":'-".

health status. and treatment outcomes.

In 2001. a literature su[\'ey conducted by EngenderHeallh noted a dearth pI tralnll1S re'I.'llr...·l',

to help providers counsel clients about their reproductive health in a comprchcn:--i\"e mann;.';

Existing training materials on counseling largely ignored a di:--cm;"ion of ..;e:\ual praL"ti..:es .lnJ

their relationship to health, Similarly. providers generally addressed the different area, l'!

reproductive health care separately. without regard for what theSe areas h3,\'e in cOllll1Wn. fl.'r

what linkages there are among them. or for how intcrreL.JI('d clients" reproductive hcalth need:-

often are. Discomfort and lack of information related to sexuality J" a health bsue remain

Widespread among both clients and pro\"iders. posing a substantial barrier to effectiw client

oriented counseling and good client-pro\'ider interaction. Opponunitie'> for addressing. thc

whole client and all of his or her reprodllcti\"c health needs too often are missed. producing a

negative impact on the public health of communities.

This curriculum responds to the identified gap in existing training matenals and fills a fidJ

expressed need for help in de\"e1oping knowledge about. skills in. 3ttitudes tl1\\aru. and com

fort with effecti\"e communication and coun"e1ing in all area.s of reproductl\t' health. including

EngenderHealth ComprehenSive Counseling for Reproductive Hea~h-Trainers' \1anual V

Preface

sexuality. It thus adopts the term sexual and reproductive health to describe the scope ofhealth issues sought by those who would receive integrated cOLlllseling.

This curriculum's intended audiences are health care providers. their supervisors, and themanagers of the programs in which they work. The counseling skills addressed here areexpected to be relevant to the provision of both preventive and curative health servicesthrough the participants' national health systems. Finally. the curriculum's participatoryapproach to defining terms and to generating profiles of po(.~ntial clients is designed to assisttrainees in addressing the realities of and exploring the reprDductive health priorities of theircommunities in a culturally appropriate manner.

vi Comprehensive Counseling for Reproductive Health~Trainers' Manual EngenderHealth

Acknowledgments

Comprehensi\'e Counseling for Reproductin' Health: An Inrl'grated Curriculum rerr6ent~ thework of many teams and country programs at EngendcrHcalth. It is the culml11atll'!1 l11 J. pwcess that began in 1998. when sexual and reproductive health (SRH) coun:-e ling tr..l\l1ll1g t(1\']-;and skills-development exercises were introduced to EngenderHealth l :-uff [r,-,m t1$, ~k)hal

teams and 12 country programs. This curriculum's development abo imnh'c,l te.lk'\\-ur ,urYeys and interviews on tleld needs. a literature search and review of tr3.in\l1~ l11~itcnah. rbnning and coordination among several glohal teams. writing. and field te:-tin,c Thu,. many in,llviduals and EngenderHealth teams must be recogni7.ed and thanked for theIr Input Into [hi,training package, tAil individuals recognized below were with EngenderHealth \\hen thi:- .:urriculum was developed or written. unk"" otherwise notco: in addition. "om ... En.::en,krHe~tilh

teams acknowledged here either no longer exist or operate under a different name

A staff-development workshop on informed choice and coun"ding tralnll1~, held til B.mgk,.kin 1998. was conduckd by memher~ of EngemlcrHealth"s Ad\anct?:' III Inlt)r111t.'d Ch$h.'e.Clinical Services Support. Postabortiol1 Care. Reproductive Health Linb,:::,>. ;m-! Tr,llnH1~

teams. with major support from the staff of EngcnderHealth'" B;m~kok reglPn;d ,)lri.:t.' andwith participation by :'taff from 12 country programs.

Follow-up suneys on counsding training nced:- pert~lining t() SRH \\crt.' Ce'!1,:U,.'t ...'.: In 20{){)

\\'ith Dr. Mavzhuda Babamarodova (Central Asian Republic s ), ....... kuJ. Ed-:\ tgnren ,c \Gh;m<l I.

Luz Helena ~vlartinez (Guatemala), Dr. Jyoti Vajpayee (India!. Dr. :\l,recn Blur de)r,'lan I.

Feddis ;vlumba (\1ala\\'i). Damicn Wohlfahrt I \longolia l. Rahda Rai i :'\erall. Dr. Annat)('\Sumayo (Philippines), Dr. Jean Ahlborg (Southt;?ast A.sial. Dr. Le\\?nt Cag:~lt~t\ I Turke\l. andKaren Levin (United States),

The curriculum was conceptualized. drafted. and rc\'ie\\HI o\er the pcril1d :000 te) :00: Q:Julie Becker. Dr. Fabio Castano. Dr. Cannela Cordero. Kn"llllJ Graff. Lime" Cinffin. C"I1IlLL'

Kamara. Jan Kumar. Andrew LevacK. ~1anisha ~1ehta. Amy Shire. Jill Tah\lutt-Hcnr.- ''':l'l'rdl

nator), and Peter Twyman. A literature search and rc\'icw of trailllng matcriab \\ ~l' pcrfprmcdin 2001 by Kathryn L. Schnippel Bistline (intern),

Field-staff interviews on the curriculum concept and dc\'cIopment were conducted In ~OO 1with Dr. A. S. A. Masud and Dr. Sukanta Sarker (Bangladesh l: Dr. \larccl Rcyncrs(Cambodia): Dr. Pia Ivan Gomez (Colombia): Dr. S. S. Bodh. :'\isha La!. and Barbara Spaid(India); Andrew Levack (Men As Partners Team): Rahda Rai (:'\epal t: Dr. Lemuel \lar;}~ig;}n

(Philippines I: Dr. Levent Cagatay (Turkey): and Dr. Isaiah :\dong (\\'cst Africa Region l.

The curriculum \vas field-tested during 2002 in the following coumnes. and the developers

thank all who assisted in these tests:

I Prior to March 200 I. EngenJerHcalth was known as ..\ VSC Internat)()nal

EngenderHealth ComprehenSive Counseling for Reproduct've Heatth-Tra:ners' Manual vii

Acknowledgments

Bangladesh: Dr. Abu Jamil Faisel (Country Director), Dr. :\owrozy Kamal' Jahan, Dr. A. S. A.Masud, Dr. Sukanta Sarker. Dr. S. M. Shahidullah, Dr. Na.-:neen Sultana, Jill Tabbutt-Henry(Advances in Informed Choice Team, New York), the participants, and all of the country officestaff.

Ghana: Patience Darko, Akua Ed-Nignpense, Dr. Nicholas Kanlisi (Country Director), FabioSaini (HIV/STI Team, New York), Jill Tabbutt-Henry (Advances in Informed Choice Team,New York), Caroline Tetteh, the participants, Ibrahim Alabl, Enunanuel Kpobi, and the rest ofthe country office staff.

Jordan: Dr. Nisreen Bitar (Country Program Manager), Dr. Levent Cagatay, Huda Murad,local trainers Dr. Suhail Abu-Atta, Dr. May Haddidi. Dr. Hccham Masa'deh, and Dr. ImanShahadeh, the participants, and the entire country office staff

Kenya: Dr. Albert Herm (AMKENI Project Director"l, ConJli:~ Kamara (Advances in InformedChoice Team, New York), Fec1dis Mumba, local trainers Jasphcr Mbungu, Anderson Yeri, andPatience Ziroh, the participants, and the AMKENl project st<:lff

Suzanne M. Plopper (consultant) and EngenderHca[th's Ev,tll.lation Team assisted with conceptualizing the evaluation plan, and Suzanne Plopper also drafted the evaluation tools. KarenLandovitz oversaw publication of the curriculum for the Publishing Team; Michael Klitschedited the curriculum; Margaret Scanlon proofread the curriculum: Virginia Taddoni designedthe cover and adapted several of the illustrations: and Anile. Kurica developed the interiordesign, typeset the pages, and managed production.

Although the Advances in Informed Choice Team coordinated the development of this cur··riculum, much of the curriculum and the participants'materials were adapted from materialsdeveloped by other teams at EngenderHealth, including the HIVISTI Team, the Maternity andPostabortion Care Team, the Men As Partners Team, and the Quality Improvement Team. Thefollowing EngenderHealth training materials, in particular. arc used widely throughout thiscun'iculum:

• AVSC International. 1995. Family planning counsefing: A curriculum prototype. Trainer'sManual. New York.

• EngenderHealth. 2000. Introduction to men's reproductive health services. Trainer'sManual and Participant's Handbook. New York.

• EngenderHealth. 2002. Integration of HIV/STI prevention. scruality, and dual protection infamily planning counseling: A training manual. Working draft. Volume I-Manual; Volume2-Handouts. New York.

• EngenderHealth. 2002. Youth~friendly selllices: A marlLlalf)r service providers. New York.

• EngenderHealth. 2003. EngenderHealth online courses: Sexuality and sexual health onlineminicourse, sexually transmitted infections online minicortrse, and HIV and AIDS onlineminicourse. [Online.] Available: http://www.engendcrhealth.org/res/onc/index.html.

• EngenderHealth. 2003. Counseling and communicating vvilii men. New York.

• EngenderHealth. 2003. Counseling the postabortion elienz.- A training curriculum. NewYork.

• EngenderHealth. 2003. Choices in family planning: Informed and voluntary decision making.New York.

viii Comprehensive Counseling for F~eproductive Health--Trainers' Manual EngenderHeallh

AcknowledgmentsThe authors also thank The Johns Hopkin..; l·ni\'er"lt) Center for Commllni,:atll'n~ Pw~r.illl'(lHU/CCP) for their permission to adapt and reprint rno..,t of the is,ue of POpulliTilln Rep(~nson GATHER (Rinehart. Rudy. & Drennan. 1998 I. FaUlll] Care International for their permIssion to adapt materials from their commuI1Ications skiJj" training gUIde I Tahhutt. 199:; I. ,HidFamily Health International for their permission to adapt materials from a guide to pro\idin~reproducti\e health services to adolescents (Barnett & Schueller. 2000 I.

For more infonnation, contact:

Advances in Informed Choice TeamEngenderHealth440 i\inth Avenuel'\c\V York. ~Y 10001 L".S.A.Telephone: 212-561-8000Fax: 212-561-8067e-mail: in [email protected]

EngenderHeallh Comprehensive Counseling for Reproductive Heaitl>-Tca '1ers /,'an'.Ja) ix

Introduction for the Trainers

Overview

Need forThis CourseThe international family planning community has hroadened it~ focu" in recent vear, t('1 take ~l

more comprehensive view of reproductive health in which family rlannin~ cr.lce Llcli\cry i"integrated with other sexual and reproductive hC;l](h (SRH) servlcc~" .-'\ J rc ... ult ltt (hi"change, a need has emerged for counseling and communication" trainIn~ th~1l wdl pn:rJ.rc "'C[

\'ice pro\'iders to:

• Perceive the client as a whole person with a range of interrelated SRH ned ... , iocluLlll1iCinformation, deci"ion-mJ.king. <L..,,,i·.tance. and emotiunal ",uppprt

• Address sensitive is"ues of sexuality with greater comfort

• Support and proted the c1ient\ "cxu;ll and reproJucti\"c n~ht:.

• ~1ore easily access resources covering a variety of SRH sen"ice ...

This curriculum attempts to meet that training need in sevcral unique way,,:

• By introducing the concept of "integrated SRH coun"cling"

• By using clienr prr~files developed hy particip:.ll1ls to rcinforce an orientatH'n (l' the inJl\IJll~ll client. whik tailoring the tr"lIning tl) local need,

• By adapting counseling frameworks from family plannll1g to help pnl\ IJer:. effccti\,:-hassess and address clients' comprehensive SRH need.,

Goal and ObjectivesThe goal of thi" training is (0 enable providers to address client:-' i.:ornprchen"'l\e :.c\ual ,tn.j

reproductive health needs hy offering integrJted SRH COllll~dlllg ...en ic::e:. \\lthin (heir L'\\ npanicular scnice-delivery ~etting.

For the purposes of this curriculum, illtl'grared scrudl and reprodUclilt' ht\drh (ilw:.\clin:; I ...

defined as:

A two-way interaction between a client and a pnnider intended to a ... "es' andaddress the cl ient' s overall SRH needs, know ledge, ~ll1J concern,. reg~lrJlc,~ of

\vhat health service the provider is working within or what "crvice the clienthas requested,

The general objectives of this curriculum are to ensure that. oy the end of the training. the participants \vill have the knowledge. attitudes. and sk.ills llecessary to carry out the followlllg key

counseling tasks:

• Help clients assess their own needs for a range of SRH s("nice'. inforrn;ltioll, and emotj(\nal

support

• Provide information appropri;lte to clients' identified prohlcms and needs

EngenderHealth ComprehenSive Counseling for Reproductive Health-Traine's ,·.!anuaJ xi


• Assist clients in making their own voluntary and informecl decisions

• Help clients develop the skills they will need to cany out Ibose decisions

Rationale: Why Integrated SRH Counseling?

Clients typically seek SRH services for one particular need or problem-e.g., family planning,

a sexually transrrlitted infection (STI), postabortion care, or some aspect of maternal health

care-and service providers typically respond to that ()II£' particular need or problem.

However, people may have other needs or concerns that contribute to their primary problem

but that are never identified or addressed by a service proviClcL By not addressing those needs,

providers may miss key opportunities to improve clients' overall health status. This problem of

missed opportunities is particularly serious in SRH service:, given the social stigma associat

ed with many SRH problems, the embarrassmeDl that many clients and providers feel about

discussing these issues, and the potentially lifc-threatcnin;.~ consequences of high-risk preg

nancies, STIs, and HIV and AIDS.

By helping providers take a broader perspective and integrate clients' immediate needs or

prOblems into their overall SRH status, this training can :lelp providers resolve issues con

tributing to clients' primary problems or prevent ti.lture SRH problems, as well as provide

more comprehensive care. By focusing on the client as a VI· bole person-rather than as a par~

ticular type of clicnt-~andby considering facLors bot:1 insiCr and outside the clinic setting that

influence a client's decision making about SRH, provider; ,vill be better able to assess and

meet a client's information, decision-making, and emotional needs. This will help the client

make decisions that he or she is more likely to carry out and follow through more effectively

with plans to seck treatment or change behavior.

Course ApproachThis training's core curriculum presents counseling as a general service-delivery skill that

relates to all areas of SRH, not as a specialized service or ~,kill for one or two arcas. This inte

grated approach teaches staff to use communication skills and counseling to assess and

address clients' SRH needs holistically, rather than rcstrictng the needs assessment and coun

seling to one service area. It emphasizes the clients' comprehensive needs, the clients' rights,

and how the decision-making process is influenced by a comhination of social, personal, and

service-delivery factors.

In designing this curriculum, EngenderHealth faced the challenge of addressing the wide

scope of counseling needs of individual clients, both in the different SRH areas and in varying

cultures around the world. A unique approach that proved sllCcessful in field tests was having

the participants develop client profiles to reflect the reali:ies of the communities and clicnts

that they serve. These profiles become the basis of case studies and role plays throughout the

training. This approach supports client~centered services by focusing on the client as an indi

vidual, while tailoring training to local needs and realitie:: (see "Before the Training Course:

Using 'Client Profiles' to Tailor the Training to Participant'.;' Needs," page xxi).

This integrated SRH counseling curriculum could be used either to develop basic communica

tion and counseling skills or to enable participants already trained in counseling to integrate

other areas of SRH counseling into their work. The goal and objectives of this course are

xii Comprehensive Counseling lor Reproductive Health~Trainers'Manual EngenderHealth


heavily oriented toward helping the particIpant:- dCH'lop attituJo and :-kill... that arc appr,)prlate for integrated SRH counseling. Knowledge i... usually Cl)\'cred in the parriL'lpant"'ll)[Jpreparation~i.e.. in prescT\'ice training~or it can he addressed in focu..,cJ prerequhltc (lr[o11ov,'-on trainings.

This core curriculum is intended to be supplemented hy one-day modules that f<Xu ... on ,~-.'itl,:

concerns and counseling needs of clients seeking particular service". These can be condLh.:tcdimmediately following the core curriculum or at some later time. A., this hook \\J.., hcmg tinalized. the training modules Viere still under dewlopment: it is anticipated that they \\111 aJJrc".'"such areas as family planning. STIs and HIV ~md AIDS. Jnd SRH couosding fl1r Illen and il)radolescents, with the selection of rnoduk:- determined by the needs of the trainee ....

Further in-depth training~whetheron its o\\n or in conjunction with thi ... ha ... ,c ,kll hcourse-can be offered in these areas through the usc of other curricula dC\'ckTcJ h~

EngenderHealth. 2 These include:

AVSC International. 1995. Family pfallfling (m/!l.lelillg: A curriculum prO!flt\pc Tr;uncr',~vlanual. :'\e\v York.

EngenderHealth. 2000. Introdliuion ro mt'n 's repmdl/cme health sen ices. :\e\\ Ynrk

EngenderHealth. 2002. Integration o( HI\!STl prnnlrio1l. SeXlli/liry, und dli<;! pnJ!c,:i, '11 In

family planning counseling: A tmininr.: Illt/mw!. Wurkln~ draft. \'oJumc 1--\LimuL \"JUInC

2~Handouts. l\'ew York.

EngenderHealth. 2002. Y()[({h~fi'it'ndlysen"icn,' .-\ /I/(/fl/w/ji II' sayleI' prot 1,1al. '\C\I. '1', lik.

EngenderHealth. 2003. COIlII.'icfing and commllnicllting H'itll mell. ~cw York

EngenderHealth. 2003. COlinseling rhe postu!)orrilJ!l etienI: .-\ rr'lIf11n ~ C!{lTHiI!UI', \C\\

York.

Course Participants and TrainersEveryone working at a health care facility where SRH scn'iccs are pro\idcd h~b a role- tI' pL..t~

in making integrated SRH counseling successful. regardless of whether the rer~on prt)\ldc,clinical. counseling, or support "en' ices. Thacforc. this curriculum can h-c ad~q,tcJ {( \ !f.Uil

scveral levcls of staff.

The term prm'iders is used here to refer to the staff who p[(1\'ide clinical or Cl)Un,citn;; ,crvices. Providers can include doctors, medical oftlcers. nurses. medical or surgical .b ... :,t,inh.

counselors. health educators. and outreach workers. The term frrmrli7lc sta(f rcfcr' [l' .!II ,urlother than providers who interact with clients. These include receptionists . ..,wirchbDarJ t1pt?r:l

tors. records staff. appointment clerks. accounts clerks. lab technicians. doormen. guards,janitors. interpreters. drivers. and maintenance workers. Finally. while wlmifllsrr<1ll\t' or

sllpen'isory staff do not actually work with clients. they usually super\'ise ()r make decIsll,ns

affecting those who do.

A team of at least two trainers is necessary for this intensi\'c workshop..-,\, one tL.llner t:Kilitates a session. the others can record infomlation on tlipcharts. monitor time. help keep the

2 A VSC Intcrnational became EngenJaHcalth In \Iarch 200 I.

EngenderHealth ComprehenSive Counseling for Reproductive Health-7ra,ners Mant.:31 xiii

__• • ·__ llIl~'~'~·;;',E!'.. '"


discussion on track with the session objectives, monitor sITl,dl-group work. and act in demonstration role plays.

It is imperative for the trainers to have extensive experiencc:nher in counseling or in counseling training. Since this training is about "integrating" different service areas into counseling,the trainers' backgrounds should complement each other ani (as much as possible) representthe range of services being covered in the training.

This manual is designed for use by skilled, experienced trainers. While the manual containsinformation to guide the trainers during a workshop and to assist them in making decisionsthat will enhance the learning experience, it is assumed nat the trainers understand adultlearning concepts, employ a variety of participatory training methods and techniques, andknow how to adapt materials to meet the participants' needs

Course StructureThis course has been designed to be flexible, to accommodnc different types of participantse.g., providers, frontline staff, and administrators or SUptTiisors-from sites offering familyplanning, HIV and STI services, maternal health care, or poslabOltion care and from differentcountries and cultures. The training package includes the c',sential materials for facilitatingthis course, including three sample agendas (Appendix A). These address the different needsof various levels of participants.

For providers, the curriculum is structured as a six-day \vorkshop on core counseling skillsand attitudes necessary for providing integrated SRH coull'.cling. The follow-on modules(when developed) wil allow for a concentration on ,-;pecifi,; SRH areas, to broaden the scopeof in-depth counseling. Providers usually have already received basic training (whether preservice or in-service) in their assigned service-delivery area and have acquired the technicalknowledge necessary to provide services, whether in fami Iy planning, STls, HIV and AIDS,postabortion care, or maternal health care. If the particip,mts have not had basic training intheir assigned area of service delivery, program planners may want to combine the core curriculum with one or more EngenderHealth curricula described earlier (see page xiii).

Frontline staff have a vital role in welcorning clients, making them feel comfortable, and gathering information from and providing it to clients. Howcvel, they are not generally involved incommunication concerning the client's decision making. Therefore, a two-day workshopshould be sufficient to address their role in setting the sl age for and reinforcing integratedSRH counseling (see Appendix A).

The support of administrators and supervisors is absolutely essential to the establishment ofany kind of counseling services, particularly integrated SRH services. Administrators andsupervisors have three options for participation in this trainmg program.

• The best option is for administrators and supervisors to attend the entire six-day training,along with providers from their facility. This would allow them to hear the providers' per·spectives on both clients' and providers' needs. Since supervisors could be expected to provide feedback and technical assistance to providers follo'wing the training, they would benefit greatly from attending the six-day course in its entirety

xiv Comprehensive Counseling lor Reproductive Health-Trainers' Manual EngenderHealth


• A three~day worbhop ha ... been ut'\dopeu w ...pecirlcall~ addrc ...... the need, ,)f a,lr11lni,tr~L

tors and supeni"ors (see Appendix A l. The three-day agenda ;.tlln\\" them to idcntlfy SRHneeds in the community and to explore their own rok in ll1eellng tho ...c need ... hy ... urrt)rtin~integrated SRH counseling sen'ices.

• Since the three-day agenda consists of a selection of se""ion" from the core cUrrIculUll1,administrators and supervisor" could attend those session ... \\'/lh lhe pr(!\iders, within thesequence of the six-day training. rather than attend a separate workshor only for themAgain. this would allow them to hear the providers' per"'pect\\e" ()n both cllent-,' andproviders' needs and to participate with their staff in action pLtnnmg,

The Training Package

Trainers'Manual

FormatThis Trainers' \lanual consists of this Introduction for the Trainer,. a dctatlcd curriculum WithsessIOn guides, and a ....erics of appendixes containing additional rnatcriak

The session guides in the curriculum han: nine hasic component-.:• ObJccti\'e"• \laterials• Advance Preparation• Time• Training Acti\'itics (o\'cnie\\)• Detailed Steps• Training Tips• Trainers' Tool s• Trainers' Options

The Objectives arc the concrete. measurable hcha\·ior.... that the partICipant.-. ~h(lLlI,1 ha\c ,kh,rtedby the end of the session. These provide the hasis for pretcsh and pl),t[(',';[.; an..:! 11'[ C'UtCi'r1ICas~eS"I1lent in follO\\"-up evaluations of the training, The: ~d,(l ~i\L' ll1L' I'~II1lo.:li'an' .,nj [[,t:n,'! .1

sense of why each sey.;ion is necessary.

The Ivlaterials section notes all of the educational and training material .... that will be need..:J fl)rthat session, Some of these mareriab need to be adapted. Je\'elopcJ. or gJthcrcd in ,llh,mc:eAdvance Preparation lists the steps that the trainer.... need to complete ahead of time anc! prL)

vides suggestions for developing tlipcharts :'1110 other tralnll1g aids.

A time is suggested for the entire session, The Training Activitie... section give;; an o\Cf\\ew 01the training methodology and time estimates for eal'll acti\'ity, The Detailed Step~ pnHIJcdetailed instructions for conducting each actinty,

Training Tip,; provide additional background information for the trainers on content or trainingapproach. Trainers' Tools are background material;; that the trainer .... \\ill need le)r the 'e"ii'nbut that are lIot meant to be distributed to the participants {for example. ;;ample statL'nlcnts (()r

EngenderHeallh ComprehenSive Counseling for Reproduchve Hea!tn-,'aners' ~.la":...ai XV


the "Providers' Beliefs and Attitudes" exercise, a sample script ['or the guided visualization in"Learning about Sexuality," and sample lists of behavior"" for the "Variations in SexualBehavior" and "Risk Continuum" exercises). Trainers' Option" outline alternative approachesto covering material presented in a session.

In addition, several symbols appear in this Trainers' Manual to indicate to the trainers whenparticular training methodologies are used or to highlight sirnificant issues. For example, eachtime a tlipchart is used to impart important information Or 10 begin an activity, the followingsymbol appears in the left margin:

Likewise, when the client profiles are used as the basis of role plays, the following symbolappears:

Finally, key questions are denoted by the symbol *, which appears instead of a bullet toemphasize the question's importance.

AppendixesThe appendixes contain explanatory materials and tools that will help the trainers conduct thetraining activities as effectively as possible. Curriculum app'.~ndixes are as follows:

• AppendiX A: Sample Training Agendas. This section co:1tains course agendas for the fullsix-day training (geared toward providers), for the two-day training (for frontline staff), andfor the three-day training (for administrators and supervisors),

• Appendix B: Daily Warm-Ups and Daily Wrap-Ups. Guidelines arc provided in this sectionfor activities to begin and to end each workshop day. (SGC "During the Training Course:Participant Feedback," page xxiv, for a more detailed desc:nption.)

• Appendix C: Promoting Informed and Voluntary Decisirm Making to Support Clients' Rightsand Address Clients' Needs. This is a presentation that C'.11 he photocopied onto transparencies if an overhead projector and transparencies are available (see Session 5, page 19).Depending on the training methodologies chosen for this session by the trainers, only someof the transparencies may be needed.

• Appendix D: Participants' Selj~Assessment of Knowledge and Attitudes: PretestlPosttest.This self-assessment is designed to be administered at both the beginning and the end of theworkshop. When it is given at the beginning of the workshop, the trainers can use theresults to customize the training to best suit the participants' level of knowledge and experience. When it is given at both the beginning and the end of the workshop, the trainers canuse the survey to gauge how participants' knowledge and attitudes changed over the courseof the workshop. The trainers must make and distribute copies of the survey to the participants. (See "Evaluation," page xxvi, for more details about using this tool.)

xvi Comprehensive Counseling fcJr Reproductive Health~Trainers' Manual EngenderHealth


• .4ppendix E: Par/iC/pa/1t Emluurion Form. ThIS and the followtnf arpendl\ ~)f!... r K\~)h !\)r

evaluating the strengths and weaknesses of the currinllul11. Thc Particlr~lT1t E\ .tluJ.ril)!1 Form

is to be used to gauge the feelings of the training participants about the ..'urrh.:ulum lIllmcJi

ately after they have completed it.

• A.ppendix F: Trainer E\'(lluatioll Form, The Trainer Evaluation Form 0ffcr' a mean, for the

trainers to provide their perspective to the dewlopers of the CUrrIculum on. an1l1ng otherthings. the participants' ability to master the information and the usefulnc,"," and rde\ance

of the different materials used. (See '"Evaluation:' page xx.\"i.)

• Appendix G: Outcome E\'(l!uatirJ!l Using Ohsern1tion ()f Client-Pm\"ider Intt·/·ddlr"!'. Thl-

and the following two appendixes offer tool, for evaluating the pUlL'omc I)! thi" training

(i.e .. for obtaining feedback on the curriculum's success at impr0\ll1g rw\iLkr,' skilb anl!

on-the-job application of these skills 1. The Ohservation Guide, incluJce! Il1 thl' JrrCndlx

are guidelines for obser:ing the counseling interaction between pro\ilkr, wlw haw heen

through this training and actual clienb. am! are me3nt to ;..mswer thc yUc'tl\)n, "Is theprovidcr applying integrated SRH coun,clin,; skills in :-,cnicc dell\c:-;-'" .inJ .. t- ~,). heW.

weIll"' (See '"Evaluation:' page x.\\"i.)

• Appendix H: Outcome EnI!lI11tion ['sing Prol'ider Intcnic\ls. The f(~rm 1'[,,\ :,!cd ~l\?r\.'

serycs as a template for interYiewing providtT:-' on ho\\- \\1.'11 they ha\\.' been ,lbk Il' apply

what they learned in the training and what challengcs they may h~l\C encpunterec! Thl'- l'

meant to complement the information pnwiJed in thc Oh~en~Hiptl GUlde,_ ~.1lld tl~ ,lT1S\\l'r

the question "'\Vhy no(')" if it is found that the prt)\-ider is not impll'Il1cl1lini= 1!1te;r.He,! SRH

counseling with clients. (Sec "Evaluation:- page xni.)

• Appendix I: Outcome Emll/utioll Using Chef/[ hZfoTi'.'\IS_ The Will tncluekd here l' t,) h:used in the months following the lI-all1ing to gather feedhack. from \.-hent' ,lb,)u, their r\?r

ceptian of the quality' of the counseling sen'ices they ha\"(~ recc1\cd. :'\~all1_ il j, h.>~t u'<..'c!lJ1

conjunction with the Observation Guides and Provider Intenie\\ F\lrm I Sl'\.' "[\,i!U,itle'n:'page xxvi.)

• Appendix J: Using Visual Aids to E.\pluin Rcproducti\c Alliltrmn (;Ild P}l.'.\i(!i(ic.:y~

Transparency Guides. This appendix pro\'ide" the trainers with a ,ct o! ,,:mrlc Jra\\ tn~>

showing different aspects of the male 3nd femalc reproJucti\c ,y,[cm, Th,,<' dr3\\1l1'>:'should be mack into tr;.\l1sparcncics. By using the transrarencie, in 'eque])..'" ,Lt\1!lO: ,)!1L' e'i:

top of the others below), the trainer can demonstrate in ~l 'implc, ,tL'r-11\ -'kp :!1.1nner the

complexity of the internal organs and how they interconnect I Fnr ~I m\)re C()J11rkte ('\pLmation of hO\.,- these are lIsed. see Session 17. page 9~.)

Participant's HandbookEach prm'ider participating in the training will recei\'c a cop~ of the PartiCIpant's Han.ib()1..)k.

which includes essential ideas to remember from the course_ summary matcna]s. discus--ion

points. and review exercises to accompany the training scssi()ns I Frontline st::!ff and admll1lS

trators and supervisors should receive photocopied handout.. hased on this materia!'l Having

the handbook minimizes the participants' need to take note" dunn.? .;c',10ns anJ enables tht'l11

to give their full attention to activities and discussions. In additlOn_ the handbcxlk proVIdes

basic background information on family planning. HI\' and STI prnentlOn. matt'mal health

care, postabortion care. SRH counseling for men. SRH counseling for youth. anJ scxuality.

Ideally. the participants should receive their copy of the handbook in aJv~I!1\.'e of the cour.;e so

EngenderHealth Comprehensive Counseling for Reproductive Health-Trainers' Manual xvii


they can become famIliar \vith the information before the course begins. The participants canalso use it as a reference after the training course is over.

Trainers should be completely familiar with the Participant's Handbook, since it details theessential ideas, discussion points, and other content meant to be covered in each session. Inparticular, for each session, the handbook contains a detailed overview of the "EssentialIdeas" conveyed in that session. Trainers should study thest' essential ideas before the start ofthe training, should keep both the objectives and the esscnjal ideas in mind from the beginning of the session, and should guide the participants toware these points throughout the activities and discussions. (It is possible to lise the essential ide;lS to summarize a session, but donot read to the partiCipants or reprint in their entirety the full sets of Essential Ideas from theParticipant's Handbook. By the end of the session, the parti.cipants should be able to explainthese points in their own word.;,.)

Not all of the informa.tion in the Participant's Handbook will necessarily be addressed in everytraining. For example, discussion points give a list of possiole responses that the participantsmay give during discussions, but not all of these points will be relevant to every group of participants. The trainers need to read these points ahead of tmc and determine which ones tohighlight during the discussion.

The participants will find the interactive and highly particiralo,ry nature of this training to beintensive; after the training, the materials in the handbook \vill help them remember the scopeand depth of the subjects covered. In addition, the participc.nts should feel free to read aheadin their free time during the workshop. Although the trainers may worry that the participantswill get "ideas" and that this will spoil the spontaneity of some activities, the conceptsand attitude change involved in this curriculum will take time for the participants tograsp. Helping them to start thinking about the concepts ahead of time will only enhance thediscussions.

However, to help keep their fOCllS, the participants should 110)1 rcad from their handbooks during the sessions. They will need to refer to their handboo.,:s at specific times for particularexercises, and the trainers should give them instructions tc do so. (This manual specificallyinstructs trainers when during the sessioIls to use the Participant's Handbook.)

Training Materials, Supplies, and EquipmentAlong with the materials provided as part of this training package (the Trainers' Manual andthe Participant's Handbook), the trainer should obtain for u.;c during the course such trainingaids as flipchart paper, masking tape or blue tack, and colored markers. In addition, manytraining activities will require index cards or large and small pieces of paper; some sessionsspecifically ask for different colors of paper, if available.

This training relies heavily on the use of flipcharts to guide or summarize discussions. Most ofthe flipcharts can be prepared in advance. However, there are dangers in overusing tlipcharts:Paper is expensive and sometimes scarce; participants can become bored with "training byflipchart," even though it is meant to be more interactive: and some information needs to besaved by the participants and is already provided in their hafl(Jbooks, Flipcharts are most often

xviii Comprehensive Counseling lor Reproductive Health-Trainers' Manual EngenderHealth


overused in brainstorming. so it is important to he .marc that nnt <;.'\('fythIn~ paI1h.'lp.rnh ,a~

in such sessions needs to be \\THten down, Spl.xific lI1structions arc fi\'cn 111 thh tramCf'"guide for when to write on tlipchans and when not to: try llut to do mlm: than i" ... ugge"teJ,

If an overhead projector. transparencies. and el<;.'ctncity are a\'ailablc, then transparcnclc, can be

used instead of flipcharts in some instances. If the resources to dc\'clup and the tran"parencie,are not available. the trainer should create tlipcharts for posting key mfoffilation during trainingseSSIOns,

Handouts are not used \'ery much in this training hecilu.;e much of the key inllumatil)i1 IS

already prO\ided to participants in the PartiL'lp,ll1!'" Handbook, Howc\cr. h,U1Jlluh ...'an bede\"eloped to address local issues. as needed,

Here arc a few guidelines for when to use tlipcharts, transparencies. or hanJllllt:..:

• Cst: tlipcharts if you arc recording suggestwns or ideas from the partIcipams I c ~ ' JurinS"brainstorming) and you want to post the infonnatlon (111 the \\'all or refer ((1 It later In thetraining or if you \\'ant the participants 10 think through a 4lle:'tion or C()nL'.:rt [()~eth('r.

• Use an o\'erhead projector and transpan:ncie ... II you want to prc~cnt ~l pi('ce l~f tc:\t Ill[everyone to read and then discuss. but not sa\"\.' {e,g .. quotation ... from a key document I

• L se handouts if you want the participants to ".l\e the infllrll1J.tion to relcl b~h.:k tll ~dt('r th;.'training.

Before the Training Course

Confirming Institutional CommitmentThe trainers should read the Trainers' .\lanual ;.Inti the Participant's Handbollk llne lim,' yu!\"kl~

to get an O\'erall sense of the purpose. content. and approach of the training, They ... lwuld thenmeet with the program administrators at the institutinn requesting or spon'll[inS th(' tr,lIl1ln~

Administrators at the service sites that requested this training: should 1>e aware (11 the SI.),lkobjectives. and intended audience for this tLlining ~C\'erthelcss. the trainer" "l)(lule! meet \1, lIhthem to clarify the purpose of the training and to confirm the time CPll1l1lilled !()r thc \\,'r].. ,h,';,

During this visit, the trainers should:

• Confirm that appropriate participants han? hcen selected

• Identify the specific areas of SRH and the community groups or client populatHm, tll heemphasized in the training I see "Bdore the Training Cour"c: l' qn,g: 'Client Prl)t,k..... t(lTailor the Training to Participants' ~ccds," page xxi)

• Decide whether to use REDI or GATHER as the counseling framework b·ee "Before theTraining Course: Choosing REDI or G.-\THER:' page xx)

• Identify and schedule follow-on modules or more in-depth content Iraimng:, thaI would n.cstmeet the training and service-delivery needs of the participants LYote: Con ... ider whetherany knowledge-oriented trainings are needed as ··prerequi.;ite"," Sec "O\'CnlCW C("\lIr,e

Approach." page xii. ~lI1d "O\'en."iew: Course Structure." page X1Y,I

EngenderHealth ComprehenSive Counseling for Reproductive Hea!lh- Trainers Manual xix


• Agree on steps for training follow-up, with timing and I~~,ponsibility assigned (i.e., to thetwiners or to program supervisors) (see "After the Training Course," page xxv).

• Identify which supervisors or administrators will attend the trainings, or plan for a threeday workshop to specifically address their needs

• Identify which frontline staff will attend the two-day training and schedule this

• Discuss the possibility of conducting baseline obscrvati0L1s and client interviews before thetraining, in preparation for outcome evaluations (see 'Evaluation: Evaluation After theTraining:' page xxvii.)

Obtaining Background InformationTry to visit the service site before the workshop is to take place. Before the training, youshould have a thorough understanding of the participants' background (including previousreceipt of counseling training. if any), work assignments, ale! training needs. EngenderHealthrecommends that trainers observe the participants at work and note the current status of SRHcounseling in their facilities. In addition, trainers should tak with the participants to find outtheir experience with SRH counseling, asking specific Clucstions related to their level ofknowledge and attitudes.

Choosing REDI or GATHERThis course introduces a new framework for integrated SRH counseling, REDI, which standsfor Rapport-Building, Exploration, Decision Making, and lrnplementing the Decision. OJ REDIwas developed specifically for integrated SRH counseling in lhe following ways:

• It emphasizes clients' responsibility for making a decision and for carrying it out.

• It provides guideli nes for considering clients' sexual relal ionships and social context.

• It addresses the challenges that clients may face in calTVi ng out their decisions and offersskills-development to help clients meet these challenges.

GATHER is a counseling framework that has been in use for family planning for many yearsand that can be adapted for integrated SRH counseling. Both frameworks can be effective as aguide for carrying out the four counseling tasks that are the general objectives for this training.

Since the REDI framework was developed for integrated SRH counseling, this is the preferredframework for this training. It is intended for participants \J,ibo are learning counseling for thefirst time, as well as those who already use the GATHER model for family planning counseling but are willing to consider a different approach. However, if participants have already beentrained in GATHER, their administrators or the trainers themselves may decide that theywould prefer to keep using GATHER. Therefore, this curnculum gives trainers the option touse either REDI or GATHER. Session 8 actually has two different session plans, dependingon which framework is chosen. From Session 8 onward, [he training sessions are generallyoriented to REDI, but include training tips and other notes to help trainers adapt the activities

3 RED! is adapted from: EngenderHealth, 2002; Pyakuryal, Bhatta. ,',[ Frey, no date; and Gordon & Gordon,1992.

XX Comprehensive Counseling for Reproductive Health-Trainers' Manual EngenderHealth

Introduction for the Trainersfor GATHER, The decision on whether [0 use REDI or GATHER ,Iwulcl be llucle clunn; theplanning phases of the workshop. based on participants' pn;\'Wlh Irall1Jn~ anJ the tr;llna,' ,1Ildadministrators' preferences,

Finalizing the AgendaAfter meeting with administrators of the host organization and the ~e[\ice site". and re,~)hmgall the issues identified under "Before the Training COllf:-e: Cpnt1fl11lng InqitutwnalCommitment" (page xi~). the trainers should read the curriculum agaill. thi" llme "lowly, andthink about each session in terms of the needs of clients and pn)\iJn" ;!t the 10L~1[ ,en Icesites, They also should carefully re\'ie\\ each session in the Particip;lIlr', Handh()ok

After field-testing and cxtensi\'c deliberation. EngendcrHcalth has determined that ,i\. .:Ll:" l'the ideal length of time for the core curriculum on counselmg skill--. \\Ith (mc-Jay {\)illl\\ -\Inmodules added as needed. This allo\\s time for the participant-- to dc\clop b.bi..: c', l~lIh.·lln.::skills. plus learn to integrate different SRH scn'iccs into one cnun,eling ,c"i"n If \hc rartic'i~pants are already well-trained in counsding skills but need to oplorc ho\\ W ink'.::r;ltc ne\\content areas into their work. the time needed for the core curriculum Ihdl can he a.:bl'[ed,but with the client profile approach maintained.

,-\.lthough -,peeific time:-- are gi\'cn for each "c""i,)[]. the ;tLlu;tl kIlC:lh III t:mL' Ih.';,',k,J "illdepend on several factors. including the partiCipants' lc\cl llf kn\l\\I('J;c ;lJld C\rCncn':-l' ,Irldeven the logistics of the workshop space. Therefore. tbe tramers ,hilL/ILl rC\lCw the !c",'rl ~LiDafter the first training day to see if the time allowed for each sc"sion "till ,cem, ,uffkicnt. :mdshould modi f\' it if necessary.

~

~

Regardless of any changes in the timing of sessions. the trainer" should loc "urc w !(,lhl\\ therecommended sequence of sessions. since latcr sessions build on knnwledgc. JttiwLk.';. andskills addressed in earlier ones. Also. the exercise..; in this course ha\c heen urdu]]y .:k'lgnc,jto achieve specific objecti\'es. many focused 011 changing attitudes, \\'hiIc it \\ill he ncc:c"ar:to adapt certain portions of the curriculum based on the particip;mts. theIr culture, :md the ,crvice setting. the trai ners should follO\\.' the instruction" a, close 1y as po"j hie

Using "Client Profiles" to Tailor the Training to Participants' NeedsPlanning PhaseOne of the complexities of designing training for integrated SRH coun"ding i, the Wide \ anety of pro\'icler5 and service settings that may be il1\'olwcl, HowC\cr. It IS as"umcd that [11\1,tparticipants in any training \\'ill come from one particular ty~ of sen Ice "etling. Ii so. thattraming: can be customized to meet the needs for intcgratmg 5RH cOlln~cling into that partiClIlar setting. For example. in some trainings. the participant'. will work only in family planningsettings and will make referrals for other sen'ices, In other trainmgs. particlpant~ (e.g .. thoseproviding postabortion care) may work in medical settings. wJlh no connection to olher ser\'lce5 and no previous orientation to counselIng. Even HIV anJ ,-\.1D5 SCf\icc~ may he .,cgrcgated from other STI services, By addressing "generic" counselmg and cornmunic;ltion ~kill.,and being structured for nexibility in terms of content ;lrea. thl~ cUrrJculum can meet the \arying needs of different providers III different settings,

EngenderHeallh ComprehenSive Counseling for Reproductive Health~Tra':lers ~,lanua: xxi


To adapt this course to fit the needs of differing audiences, the key is in how the trainers

conduct Session 4 (on problem trees), which then leads to Session 6 (on developing client

profiles). The client profiles, which function like case Hudies, are referred to repeatedly

throughout the training and are used for practicing counsel ing skills in role plays. These pro

files, which are based on needs identified by program planners and participants, give the

training a local focus and offer the participants a sense of "ownership"-that these are the

challenges faced by their clients, in their service sites, and in their communities. The profiles

also give each problem a face, a name, and often a family scenario within which the problem

must be addressed.

Although the participants are the ones who develop the prufiles, at the beginning of the train

ing they may not be aware of the range of SRH needs ancl concerns of people in the communi

ties they serve. Thus, during the planning phase, the trainers should involve local program

planners and administrators, to identify the needs and concerns to be addressed within the

course. Although the "problem trees" session begins wilh brainstorming to generate a list of

real SRH problems that people face, the trainers should b,; prepared to guide the brainstorm

ing to ensure that the participants cover the needs that were discussed during planning. After

the brainstorming. the trainers select which problems will be developed into problem trees,

reflecting the needs identified during the planning phase. By guiding the brainstorming, the

trainers are assured that the appropriate problems needed for the training will be selected.

During the Training

Although SRH necds identified in the brainstorming (Se:;sion 4) will vary depending on the

community and on the participants, in general the problem trees (and, thus, the client profiles)

should cover the following categories:

• Men• Women• Unmarried youth

• Family planning needs

• HIV and STI needs

• Maternal health care needs

• Postabortion care needs

During the brainstonning in Session 4, thc trainer should probe to make sure that all key SRH

areas are included. For example, if a program focuses on family planning and the participants

brainstorm only about the family planning problems of the typlcal married female clients, train

ers should ask: "What about family planning problems faced by men? By unmarried women?

By adolescents? By postabortion clients? By people who are HIV-positive? By postpartum

women? What about other problems faced by married women who come to your clinics?"

In Session 6, the participants will develop client profiles based on each of the problem trees.

These profiles will include the demographic and social characteristics of each client, plus

descriptions of the client's SRH needs, the decisions that the client is making, the infonnation

he or she needs to make those decisions, his or her acces:~ {or not) to services, and the client's

feelings about his or her situation. The problem trees and client profiles determine the focus of

the discussion throughout the rest of the training.

xxii Comprehensive Counseling for Reproductive Health-Trainers' Manual EngenderHealth


Howewr. not all issues have to be ('o\"(~rcd in thc-.c initIal profile". In later ';C';"ll'lh. the lLll1lers can add "new developments" to each client profile. introducing ...ome chJnge In the dlen(,physical. social. or emotional condition. The new de\"l~lopmentscan be u.;cd to help the PJ.rt1Cipanrs focus on issues that they may have been reluctant to bring out in the initial pf\)tik .... a,well as to raise the problem of missed opportunities by making sure that the clien! ha.; nh)fCthan one SRH problem that needs to be addre"scd. For cxample. one profile might be \)f .1

male STI client who is reluctant to tell his wife Joout his infection. and the new de\c1opmcntmight be that he learns his wife is pregnant. ~ow. O\'cr and above the standard STI b.;,ue .... theprofile must cover antenatal care. plus the client's need to communicate with h1'. \\ ifc ab,'utSTI treatment issues for her and the felU". Trainers can u"e this technique to lntrl1du\.·c ...uchissues as power imbalances within relationship.... women's lack of control lHCf when tl) hdh'sex. denial of services or information to unmarried and adolescent women. men', lack l,faccess to services, the risk dUring unprotected sex nf HIV and 5Th I as well J' uillnlenJeJpregnancy). stigmatization of people who arc HfV-positivc, involuntary HI\' testing, and pre.;,sure for sterilization in postabortion scn'ices,

Participants arc instmcted to de\"elop fi\e client profile .... based on fiVe probkm tfeC'. Thl'number was chosen because it allO\\'s for some nriation in client... and nec;:k mClrc Ih~m !i\~

profiles would create time problems. particularly during the plenary di,cu ...... llm' af!l'l ... mallgroup work. when time is needed for each group to share their ftndll1g~.

However. the trainers should develop a sixth client profile. Scwral coun ...elll1g rr,idi.:e ,e,sions during later sessions require demonstration role plays by the trainer .... Fl)r ih,.><.: fPIc

plays. the trainers will introduce their own profile-the "sixth client." The trainer, can ai",use this profile to address SRH necd~ that dl\; not cun:red ill the other [1\c.

During the Training Course

Creating a Positive Learning EnvironmentMany factors contribute to the success of a tr:.lIning course. One key L.lCtor h the karninfenvironment. Trainers can create a positive learning environment hy:• Respecting each participant. Traincfs should recognize the l.;no\\lcdgc ;ll1'J ,Kill, tklr rho'

participants bring to the cour~c, and can :-how re-,pecr for them hy rcmcll1benl1~ ,mel u,in~

the participants' names. encouraging them to contrihllte to discu ...... ion.;" and r('qllc'tll1~ thclffeedback on the course agenda.

• Giving frequent posi/h'e feedback. Positive fecdhack incre~bes people'.;, lllotj\;jtion ;H~L! IC:lming ability. Whenever possible. trainers should recognize the particip:.tnts' corn:..:t r'::-'p',n'c,

and actions by acknowledging them publicly and making such comment... a, "Excellentanswer'" "Great question~" or "Good work ,., Trainers can also validate the p~1rticirant"

responses by making such comments as .. ( can understand why you would feel thar way ..... ·

• Making sure tllat the parricipaflts are cnmforwble. The training rOO!TI(s I -.hpuld ~ well-lit.\vell-ventilated. and quiet. and should be kept at a comfortable temperature. Breaks for re.;,t

and refreshment should be scheduled.

EngenderHeallh ComprehenSive Counseling tor Reproductive Health-Trainers' Manual xxiii


Presenting Sensitive ContentThis training course addres.<.;es many topics that particip:mts may find difficult to discuss.

While this manual provides suggestions for ways to discuss m~my topics in a group setting,

trainers may face situations in which individual particip:.nts (or groups of them) hesitate to

join in discussions, are judgmental, or inhibit other participants from expressing their feelings

freely. To encourage risk-taking and create an enviromrcnt in which the participants feel

comfortable discussing and absorbing new content and i{kas, trainers may use the following

techniques:

• Acknowledge that it is normal to feel nervous, anxious, or uncomfortable in new and unfa~

miliar situations.

• Begin with less-sensitive content and build up to content that is more sensitive.

.. Use icebreaker activities at the beginning of the trail' ing workshop and after breaks to

encourage team-building and comfort.

• Use small-group work to allow the participants to exprc~;s their feelings in front of a smaller

audience. Similarly, split the groups by sex, if appropriale.

• Use paraphrasing and clarification techniques to demonstrate attention to what the speaker

has said, to encourage the speaker to continue speaking. and to ensure understanding.

• Share your own experiences, including situations in whic) you were and were not successful.

• Give constructive feedback to reassure the participant tl'at his or her remarks are acceptable

and appropriate and to encourage additional participation.

Participant FeedbackTrainers should set aside a segment of time at the beginning of each training day to permit the

participants to raise issues that might interfere with learning, such as those related to personal

situations, accommodations, or content. Depending on the size of the group, a period of IOta

15 minutes should be sufficient (see the Daily Warm-Up, 1\.ppendix B).

Similarly, the trainers should set aside a segment of tim..~ at the end of each training day to

allow the participants to share their learning insights and their assessment of what did or did

not go well for them that day (sec the guidelines for Dai 11' Wrap-Up sessions, Appendix B).

This assessment w!ll enable the trainers to adjust the agenda as needed and will give the par

ticipants a chance to comment on how the training course is progressing.

At the end of the day before the last training day (e.g., day .5 of the six-day training or day 2 of

the three-day training), the trainers might ask the participants if they would like anything dis

cussed in the training to be clarified or if they would like anything else to be included on the

last day.

Clients' RightsThe participants mayor may not have direct contact wi'b clients during the integrated SRH

counseling training. However. they may observe some client-care activities during the train

ing, either at their own facility (if the training is conducted on-site) or during a facility visit (if

the training is conducted off-site). As is the case with ::"1I1y medical service, the rights of the

client are paramount and should be considered at all times throughout the training course.

xxiv Comprehensive Counselng for Reproductive Health-Trainers' Manual EngenderHealth

Introduction for the TrainersEach client's pennission must he obtained bdore tho\e who are partiLip:l!in~ In the tfJInln~

obsene or assist with any aspect of client care. :\ client who refu:--c.-. to grant l'Crmi""I~'n t~,

ha\'e the participants pres"nt when sen'ices are pro\'id"d ... hould not hI.' denic<i ...efvicc .... Ih,r

should any procedure be postponed

CertificationBecause this training focuses on applying knowledge. attitude..;. and kill~ in intcractlon ... withclients, it is impractical to certify the competence of the participant at the con.:lu ... 1011 01 thetraining, EngenderHealth believes that the participants' competence hould he C\J.Jll~\lcd altefthey return to their facilities and apply what they haH: learned. It h only In the real work ... ctting that the participants' abilities can be determined and the Impact of the training Js"e ..."cd,Therefore. EngcnderHealth does not recommend that the partlupants rCCCl\C 1.:crtlfi(~llC'" orcompetence immediately following the training.

The institution providing the training should determinc whether It want...; to give the rani-:'Ipants some other type of certification. For example. in:-titution" can chocbc w rr,,\i<k tnl''''''who complete the course with a certificate of attendancc,

After the Training Course

Lc:arning about integrated SRH counseling does not end \\hen thi ... cnUhC I' (,'mplctcdParticipants' sensitivity to clients' need:-- and appreciation of potcnti~,d harrier..; tl.' cC1un ... c!Jrl::::will increase as they implement this approach in theIr \\ork ...ening...;,

At the end of the course. rno'it participant-; wIll ha\'e ~~lll1ed l1e\\' kl1o\\k<!~e. ~re,l[('r d'f1lI<'l'.

and enhanced skills for discussing SRH issues with clients, They \\ill abcl ha\" cr;,',ltt,'J ,ill

"action plan" listing at least three specific ways in which they would like tp 11l1pkmcT1t wh,j[they hm'e learned in their work setting, After the course. thc trainer ... pr prn:;ram ...Litt ..;h,'ul<!follow up with participants and administrators at the participants' lacllltlC's to JC'krmlll"whether those plans have been put into action.

The trainers should determine the strategy for folkm'-llp \\'ith "'llpeni ... or... bl.-'f,)re the \h)rk ... lh1!'(see "Before the Training Course:' page xix!. During till,.' \\(lrk"hpp. the 1',lrti,:il'.lT1t, ':H'llLi b,-'informed who will be conducting follow-up and when and ho\\ It wIll be conductc.1 ,SC ... 'It'il32, page 171).

Follow-up can be provided in several different ways. dependIng on the partiL'ipants' needs. thetrainers' availability. and financial considerations, Follow-up Il1cchamsms lI1c1udc:

• Visiting the participants at their jocilitit's. Follo\\-up \'isl!s can he conducted hy the trainer ...initially (but preferably with the supervisorl. with the intention that the sUj)Cr.isor wouldaddress counseling a~ part of his or her routine monitoring. The o\'Crall purpose of the ...evisits is to provide feedback and support for the partiCIpants in implementing inte~rated

SRH counseling at their sen'ice sites, Tasks include inten'iewing the participants to asSC';'their progress in carrying out the action plans. ohser.·ing counseling. talking with client ....providing feedback to the participants on coul1se]lI1g contcnt and skill.;, and meeting Withthe participant and supervisor to discuss problems they lld\'c identified,

EngenderHeallh ComprehenSive Counseling tor Reproduclrve Health-Tramers ~.'allual XXV


• Arranging site visits for the participants. Being able to visit facilities that already provideintegrated SRH counseling will enable the participants tl) observe and obtain helpful advicefrom health care workers who have successfully implcffil.~ntcd these services.

• Publishing a newsletter: The trainers can request a quarterly update from the participants(by letter, e-mail, or telephone) in which they descrihe Ihe steps they have taken to initiateor expand integrated SRH counseling. Based on the r.~<;ponses, the trainers can developa simple quarterly newsletter to send to the participant~·;, summarizing their successes anddifficulties in implementing such services and respondin:.~ to frequently asked questions.

• Establishing a peer-support nern:ork. Peer support has)een found to be an important element in sustaining skills and commitment after a com seling training (Kim et a1., 2000).The trainers can prepare for the participants a list of cof'tact information (if the participantsare from more than one facility) and distribute it to each (and, if possible, prepare a list ofothers in the participants' geographic area who have receIved the integrated SRH counselingtraining). The trainers also can encourage the participant~., 10 stay in contact with one anotherafter the workshop, to help each other with questions ;lrld with concerns about providingintegrated SRH counseling services. Supervisors can supDon this strategy by assigning smallgroups and authorizing them to meet or otherwise contaci each other on a regular basis.

EvaluationAn important part of the training, evaluation allows the participants, trainers, and programplanners to determine whether the training has met its objectives. Tools are included with thiscurriculum to cover evaluation during the training and on-the~job evaluation after the training.

Evaluation during the TrainingThis curriculum contains a number of tools that give the trainers and the participants an indication of what the participants have learned and that help the trainers determine whether thetraining strategies used were effective.

• Participants' preworkshop and postworkshop se(!"assessmenl of knowledge and attitudes.This written tool is meant to be completed in 30 minute~ by participants in the provider andadministrator trainings. In field tests, many participants could not complete the tool when itwas given at the beginning of the course, but all were <lhIe to do so at thc end. This selfassessment addresses many key objectives of the comsc, focusing on basic knowledgeabout counseling and on common misperceptions and ahtudes that can significantly affecta participant's ability to provide integrated SRH counsclmg. The trainers can usc the preworkshop results to identify key areas that will need special attention during the training.After correcting the postworkshop assessment together with the participants at the end ofthe course and returning the corrected pretests, trainers have an opportunity to summarizecourse content and to give the participants a sense of how much they learned.

• Daily wrap-up sessions. As noted earlier, these 15-minmc closing sessions for each day arekey indicators of what the participants learned and what tbey intend to apply from the day'ssessions, what worked well for them and what did not, and whether the objectives for theday's sessions were met (see the Daily Wrap-Ups, Appendix B). If the participants indicatethat objectives were not met for some of the sessions covered that day, a trainer might ask theparticipants to review some of the material in their handbooks that evening, might scheduletime to return to that issue the next day, or might notc thc topics for follow-up visits (see"After the Training Course," page xxv).

xxvi Comprehensive Counselin~1 for Reproductive Health-Trainers' Manual EngenderHealth


• rVorkshop em/uarron hy parriCljJanrs, This written tool. which is meant t(l he ('\)mrkk.! In l:'ito 20 minutes. allows participanh to gl\"(~ feedhack on the on'rall proce" and ImrncOlateresults of the training course. It provides feedback to the trainers on the paf1lClpanh' 'en,e ()f

\vhether objectives v..'ere achieved. the rele\'~mce of the course. the effecti\'ent?'s nt the tr~lJntn~

activities and the trainers themselves. and the participants' suggestions for imrwvernenl.

Evaluation after the TrainingThe true test of the success of integrated SRH counseling training is whether the panlcipmt:-

are conducting such counseling at their service sites after the training. This empha,ifes thcimportance of good follow-up of all training workshops. As noted in "Bef()re the Trail1in~

Course" (page xix), trainers should determine the plan for follow-up, Il1CILlJIn~ e\alllJll,m.with program planners and site administrators prior to conducting the course.

• FollOW-lip ~·i5its. These were discussed as part of training follow-up to reinf()rec k..lmin::;

and provide technical assistance to providers and supern'or:-- In "o!\ll1f !'rl1Dkm"However. they also pro\'ide important feedhack to the trainer" on the effe,IJ\enC" clf tktraining itself and ways to improve it.

• Outcome el'a!uutir)fJ guidelines. This training is expectee! to impw\"(' the parliL'lr~tn[ ... · ,kill-.in providing integrated SRH coun"eling (/Jld in effectiwly applying the:--c ,kill- tt) ,en iccdeli\'ery, The indicators rellect the objectives of the truining ane!the kn0\\kd~e, Jtllllh.k"

and skills necessary for achie\'ing these objectIves. Gauging this trainin{, dfcc[ih'nc', interms of outcomes will require evaluation of participants' on-thc~joh pcrf()rm~lt1(c. u,in:; theObservation Guides (see .-\ppendix G L on :.it lea"t two occa"ions: prior [t l lr~lln 111:; ,;",'r .1

"baseline" to compare to the posmaining results) and at some lntena] fnlkl\\ Ing t!"ail1lo,:::

(for example. at three and/or six month:-- follo\\'in.:; trainlllg l.

Competence in counseling is evaluated through observation of counseling and thf(1u~h interview's with participants and clients. and so is necessarily somewhat SUbjCL'[j\C, Tel nuke theobservation process as reliable as possible from one evaluation to another. the ,ame inJI\].luals should conduct the evaluations each time. and these e\'alllator" :--hould he cpm[X'knt inthe skills being evaluated. The trainers should not do the evalu3tiom. although they can hdporient local evaluators to the desired outcomes of the training,

The results of outcome evaluation can be lIsed in many \\'aY5. Program pLumer....H1tl ~h:lmlllhtra

tors will want to knml,; if the training had the desired effect on sen'ICc Jdiwry lIe. c:--t..l[lII,hingintegrated SRH counseling services). If it did no!. these tools pro\'ide clues f(lr \\ lut the [la.mas

are and whether they are training-related or can he traced to other ;)speCl'> pf ~ef\lCe deliver:.The participants will want to know how clients respond to this approach [0 epun,cling J.nd ho\\

they can improve their skills. Trainers will want 10 know if their training arrrodchc' werc dfective in imparting appropriate knowledge. attitudes. and skills for integrated SRH counselmg. andhow these approaches can be strengthened. Finally, EngenderHealth would like to know the out

comes of these trainings in ditferent countries, so lessons learned can he shareJ t">oth ;lerl)'''; theagency and throughout the health and development community,

EngenderHealth Comprehensive Counseling for Reproduchve Health~Tral~e's' P.lanual xxvii

EngenderHealth

Part I

Principles and Approachesfor Client-Centered Communicationin Sexual and Reproductive Health

In thi~ section. the wClrbhnp participant'> c(ln~ider the C(lnk'\t

of sexual and repn,c!ucti\'c health ISRH I. identif: tYrlL~ll SRH

prohlems fact:'d hy people in their c(lmmunitic~. ;inc! dC\eh1p

"client profile~" that \\tll he lIsed [(If ca"'" ~tullie' ~lI1ll rL'k

play,.; throughout the re~t (If the tr~linin:;. Sil~ ...'(' l','ulbl·itn~

focuses on facilitating deCIsion making. the trailllng sC';Sl\ln~

here e"plore the client's JechlOll-l11aking rr,'cl>~ lrl1m thr..'

perspectin:- of "e\ual and reproductiYc righh. informed ~lHJ

yoluntary decision making:. and client~' fight... in the

service selting. PfII1Clple" of clicnt-prcl\i,lc Int('r~IC!l(ln .md

counseling: pro\"l(.k the foundatIon (pr ,k\clui'in:z h.c:

counseling skills. attitude". and knowledge In the rc~t "f the

trainll1g.

Comprehensrye Counseling for Reproductlye Health--Trainers l\lanual 1

Session 1Welcome and Introduction

Objectives

• To officially welcome all participanh and guest-; and to introduce (he paflh:lp;.tllh. gue:-h.

and trainers

• To describe the purpose. goal. objecti\·es. and agenda for this training

• To administer the pretest

Materials

• Paper and pens

• Workshop agenda (.-\.ppcndix A. page 177)

• Prete;;t L\ppendi\ D. page '::~3,

Advance Preparation

1. Re\'iew Session 1 in the PartiCIpant's Handhook (page 3t. Cpn."iJn if or h(>\\ \ ,'U \Llf1! t,~

use the Participant Work:--hcet for this session (see \;ote to Tr~Llncrs. P,I~'-' :' I

2. Identify a representatiye of the "host" organization tll formally open the \\ \lrk,h"J' (:\dl\lI:

A). Brief him or her on the purpose. goal. and ohjccti\"\?s of the tr~linin~.

3. Identify and brief any guest speakers thoroughly in ach·ance. to cxplall1 the I~LJrr\)'C \)f thetraining and to be clear about how long their opening remarks should he anJ \\ hat 'ubic.:r,they shall Id coyer (Activity B 1.

-t. Arrange for refreshments. if appropri:He. \Rcfreshmenh could he ,c[\'c,l jlri, ,,- t\~ the ,t~~n "fthis sc,>sion.)

5. Prepare copies of the \\'orkshop agenda for all guests and participant'.

6. Prepare one copy of the pretest for each participant.

7. Arrange for all other materials necessary for the training w be in placc ht:(t1re the ,tart l)(

thi" session

Time

I hour. 15 minutes Training Activities

A. Welcome/introduction., .

B. Opening remarks .

C. Introduction of trainers and pa rtlcipants

D. Presentation/discussion .

E. Pretest.............. . .

Time:; mlr1

. .. 10 min.

.... 15 fT]!n.

15 m,n.

EngenderHeallh Comprehensive Counseling for Reproductive Hearth-Trainers' Manual 3

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Session 1

Session 1 Detailed Steps

Activity A: Welcome/introduction (5 minutes)Have a representative of the local "host" organization (the "moderator") formally open the workshop, by welcoming the participants, explaining the purpose of the training, and introducing theguest speaker.

Activity B: Opening remarks (10 minutes)The guest speaker makes his or her opening remarks.

Activity C: Introduction of trainers and participants (15 minutes)Have the moderator introduce the trainers and ask the participants to introduce themselves.

~ Training Tip

Depending on Lhe number of participants. they may introduce themselves very briefly (by name, where they are from, where they work,and what their job is) or they rnay m~lkc a somewhat longer statement (c.g., aJl of the ahove, plus why they believe they were selectedfor the training or what strengths they hring to this work). Even witha large group, a brief icebreaker exercise would be to ask them toadd one thing interesting about the town or village where they work.

~

Activity D: Presentation/discussion (15 minutes)

1. Refer the participants to Session 1 in their handbooks (page 3) and briefly discuss the section stating the goal and overall objectives for the workshop. (See the Introduction for theTrainers [page xi] for background on why this integrated SRH counseling curriculum wasdeveloped. Your comments here can be drawn from that, depending on the background andinterests of the participants.)

2. Hand out the agenda for this workshop and review it 'N'ith the participants.

3. Have a representative from the host organization or the training team address logisticalquestions from participants.

Activity E: Pretest (30 minutes)

1. Explain to the participants that, to get a sense of the effectiveness of the workshop, youwould like to have them complete a self-assessment of their knowledge and attitudes, bothat the beginning of the workshop and at the end. Expl ain that this is not a test, and that thetrainers will use the results to judge how well they and the workshop were able to meettheir objectives, not how well the participants lemned. Assure them that all answers andscores will be confidential.

4 Comprehensive Counseling for Reproduclive Health-Trainers' Manual EngenderHealth

Session 1

... Training Tip

Confidentiality is important for these sclf-assessmeoh-the ,(ore.'for individual participants arc speCifically not to be shared withprogram managers or administrators. The test fonm currently have aplace for participants' nan1CS. This IS to make it easier 10 (omparepretest and posttest scores. and to rdum the pretest' to participanhat the end of the training. HowewL if you think that h:mng the participants' names on the fonns would make it too difficult lO maintain

confidentiality. you can write a number on the line for the name. Inthis case, participants must be responsible for remembcnng theirnumbers until the end of the workshop. and for being sure \0 writethe same number on the postte.. t ~t, tht:Y wrote 00 their pretest.

2. Distribute the pretest (which appear.. in Appendix D. page 2331. brietly pointl)U! the Jllterenrsections. and ask if the participants han: any 4uc,tions, Give the participant.' 30 mll1utc.; tl)complete the test. with time checks at 20 minute.; ~lTIcl 2:- minute" I In tield te,ts pf thl' curriculum. some participants were not be able to complek the prete.;t in 30 minutes. but allwere able to finish the posttest in that time.l

3. After collecting the pretests. explain that group scores will be announc<..'J the next Ja~. Yl'Llwill not be revie\ving the test questions themscln:,,,, but all of the nece""ary Il1tprmatll)!1 [l'

answer these questions should be co\'ered during this training workshop. The prcte'b themselves \vill be returned at the end of the training. after the participant" 11,1\(' taken the

postlest. so they can compare their own scores belore and after the \\orbhl'p,

Note to Trainers

Participant \VorksheetsFor this and a few other sessions. a Participant Worksheet i" proviJedin the Participant's Handbook (page 4 \ as an 0/,/jona! trainin~ l\'l) IThis may be usdul in any of the following ways:

• As a "homework" assignment. to reinforce important concept" frl'!l1the session (Participants can work on it Juring the e\'Cning and ,haretheir thoughts the next day. )

• As an alternative group exerCIse. to add to the session or to repla..::can activity currently planned

• As a \vay of orienting participants who haw missed the session(This is particularly important for the first day. when the key can·

cepts of the training are being established. but when participant-.traveling from some diqance may arri\e late.)

• As a more engaging way of refreshing participants' memOrIes of thesessions at some later time (e.g .. as part of the training fol](~w-up I

EngenderHealth Comprehensive Counseling for Reproductive Heal:,,-Tral~er5' p..~anual 5

Session 2Defining Sexual and Reproductive Health

and Integrated SRH Counseling

Objectives

• To define the terms sex, sexuality, repmducti\e health. sexual health. and sexual t171d

reproduclI\'e health

• To explain the difference between integrated SRH counseling and integrated SRH scnices

• To name at least four health and social services that are neces"ary to meet ~orJe'" SRHneeds and to know where these services arc provided in the partIcIpants' COmrnUnIl1C"

Materials

• Flipchcm paper. markers. and tapc

• Pens or pencils

• Extra writing paper

Advance Preparation

l. Review Session 2. in the Participam's Handbook (page 5). Prepare a I)-minute prescmatic1non the definitions (Activity C).

2. Prepare a f1ipchart divided into four sections. with each of the tenn" "Sex'" "Sc\ualtty'""Reproductive health:' and "Sexual health" heading one sectHm I "cc Octo\\' I (.-\Lli\'ity .-\ l.

Sex

Reproductivehealth

Sexuality

Sexual health

EngenderHealth Comprehensive Counseling for Reproductive Health-Tra!ners' 1.1anua' 7

PREVIOUS PAGE BLANK

Session 2


Activity A: Small-group work (10 minutes)

I. Introduce the session by noting that some participants may he thinking. "J kno\\' afl0utreproductive health. but why arc they always saying 'sexual and reproductl\e health" And\vhat is integrated SRH counseling? How is that different from what I am already dpinf'"Explain that if they are confused. many other people probably share their confusion.

2. Divide the participants into four groups.

3. Give each group several pieces of writing paper and a marker.

4. Post the prepared flipchan and assign one of the headings I"sex." ":--cxualit\:' ":--exualhealth:' Or "reproductive health") to each group.

5. Ask the participants to spend 5 minutcs defining their term and to wnte thelr defil11tlon ontheir paper with the marker. They should write large enough so people can read It on theflipchart. They can use as many sheets of paper as they need. EncDur~lfc the r~1rticiralll:-- t~)

avoid using the words sex. sexl/CII. or reproduction in their definitions.

Activity B: Discussionlbrainstorm (15 minutes)

I. One group at a time, post each group's definition papers on the tlipchart. Ask a member ofeach group to rcad their definition, and ask the rest of the pal1icipant:-. if they ha\e cltffer,-'ntideas about this term.

2. Ask the participants ahoLlt the similaritie:-- and difference:-- between ":--e\.-- ..incl ··:--c\U..l)it:"

and between "sexual health" and "reproducti\"e health."

3. Xote that SRH is a relatively new term that i" finding common U.''<lgC ll1 intcrnatWllal he.i!rhcare organizations. Ask the group to describe what they think SRH might lx'. ha.:-.c,1 l,n th;.'other definitions.

4. On a separate flipchart. write "Sexual :md Reproductive Health Care SenlCcs."· Bram:--tlmnwhat health care services would be included in SRH: list the participant:-.' re.;ron.;e.; t'n theflipchart.

Activity C: Presentation/discussion (20 minutes)

I. Give a short presentation on the definitions of sex. 5l'.Waliry. reprodllctil'l' heo/th. seXUd!

health, and SRH. based on the infom1ation in the Particlpant'\ Handbook Ipage.; (-, to 91.Compare these "official" definitions with those of the small groups, :\ote any parts of thedefinitions that were missed and clarify any remaining question'>. ( J5 minutes I

2. Ask participants to tum to Session 2 in their handbooks. to "Components of SRH Care"(page 8). Review this list. then return to their own list of SRH sen'ices on the tllpchart Jndsee if any should be added.

3. Review the final list, asking the participants which services are a\'ailable in their communities. Place a check mark next to each one that is available Ask the participant-; to .;a~ wherethe service is provided. but do not write down the locatIon.

EngenderHealth Comprehensive Counseling for ReproductIve Heallh-Tra:ners' \tanual 9

Session 3Why Address Sexuality?

Objectives

• To explain how the quality of integrated SRH counseling and seryicc", can he imprO\ed byincluding a focus on sexuality issues and concerns

• To describe barriers or challenges for providers in addressing sexuallt~ in integrated SRHcounseling

• To identify strategies for helping providers feel more comfortable about and be betterequipped to address issues related to sexuality and sexual health

Materials

• Flipchart paper, markers, and tape

Advance Preparation

I. Read Session 3 in the Participant's Handbook (page II) to review the key Ji~(:u:':'-lon poilll:to be covered.

2, Review Trainers' Options (page 13) to consider altematiyc ways to ..:onJu(:t thl:- :,c:-~il)n· ...activity.

3. Prepare three flipchans with a heading for each of the discussion lopics-"Why is it important to address sexuality as a part of integrated SRH counseling')" (Aetiyity .-\ l: "What bamer"or challenges might providers experience in discussing sexuality issues with c!Jent..;)"(Activity B); and "What can providers do to feel more comfortable and ~([er equipped toaddress issues related to sexuality?" (Activity 0.

Time

45 minutes Training Activities Time

A. Brainstorm/discussion.................... 15 m;r..

B. Brainstorm/discussion .. ,................. . . , .. 15 min.

C. Brainstorm/discussion . 10 min

O. Summary., , .. , . .......... 5 min.

Nore: This session is adapted from: EngenderHealth. 2002.

EngenderHealth ComprehenSive Counseling tor Reproductive Heat!h-Trainers' Manual 11

Session 2Defining Sexual and Reproductive Health

and Integrated SRH Counseling

Objectives

• To define the terms sex. se.llwlity, repmductil-e health. sexual health, and sexual Lmd

reprodueth"e health

• To explain the difference hem/een integrated SRH cOlUIseling and integrated SRH sen/us

• To name at least four health and social sen'ices that arc necessary to meel peorle'" SRHneeds and [0 knov,' v,'here these seryices are prm"ided in the pJrticipanI< communitie"

Materials

• Flipchart paper. markers, and tape

• Pens or pencils

• ExIra \\Titing paper

Advance Preparation

1. Review Session 2 in the Participant's Handbook (page 5). PrepJre a 1)-llllIlUIe pre'enIatlOo

on the definitions (Acti\"ity el.

2. Prepare a flipchart di\"ided into four sections. with each of the term, "Sex'" "Se\.uallt~""·

"Reproductive health," and "Sexual health" heading one section (see below I I.-\":llvity .-\ 1.

Sex

Reproductive

health

Sexuality

Sexual health

EngenderHealth ComprehenSIve Counseling for Reproductive Heatth-Trainers' r,1anua l 7

PREVIOUS PAGE BLANK

Session 2

3. Prepare a f1ipchart with the definition of integrated SR I-I counseling (Activity D).

Time

1 hour Training Activities Time

A. Small-group work 10 min.

B. Discussion/brainstorm _ 15 min.

C. Presentation/discussion... . 20 min.

D. Discussion.............. . 15 min.

Note: This session is adapted from: FngenderHcalth. 2002

8 Comprehensive Counseling for Reproductive Health-Trainers' Manual EngenderHeallh

Session 2



1. Introduce the session by noting that some participants may be thinking. "I know ar.outreproductive health. but why are they always saymg 'sexual and reproductiw hcahh') And

what is integrated SRH counseling? How is that different from what 1 3m 3.1rcady doinf)"

Explain that if they are confused. many other people probably share their confusion.

2. Divide the participants into four groups.

3. Give each group several pieces of writing paper and a marker.

4. Post the prepared flipchart and assign one of the heading" r""ex:' ""cxualit\:' ""cxualhealth:' or "reproductive health") to each group.

5. Ask the participants to spend 5 minutes defining their term and to write their definition \)ntheir paper with the marker. They should \\Tlle largc enough :-.0 people can read It on theflipchart. They can use as many sheets of paper a~ they need. Encourage the rarticlpanh tl)avoid using the words sex. sexual. or reproduction in their definition".

Activity B: Discussionfbrainstorm (15 minutes)

1. One group at a time. post each group's defInition papers on the tlipcharl. Ask a member ('{

each group to read their definition. and ask the re:-.t of the participants if they ha\c cliffcn:ntideas about this term.

:2. Ask the participants about the si mi laritie~ ~ll1d d illcrenees bet wCen ",c.\.·· aId .. ,eX u.d it:- ..

and between "sexual health" and "reproducti\~health."

3. Note that SRH is a relatively new term that is tindmg common usage in intemJ.tl01L.d heJ.lrhcare organizations. Ask the group to dcscnbe what they think: SRH might be. bascJ \.)n [heother definitions.

4. On a separate flipchart. write "Sexual and Reproductive Health Care Senlces" Br~lln~!Orl11

what health care services would be included in SRH; list the participants' re~pon~es on the

flipchart.

Activity C: Presentation/discussion (20 minutes)

1. Give a short presentation on the definitions of sex. sexuality. repmducti\e health. <;exualhealth. and SRH. based on the infomution 111 the Participant's Handbook I page" 6 to 9 \.Compare these "official" defInitions with those of the small groups. :'\ote any pMt" of the

definitions that \\lere missed and clarify any remaining question:-." (15 minUfeS!

2. Ask participants to tum to Session 2 in their handbooks, to "Components of SRH Care"

(page 8). Review this list. then return to their own list of SRH sen"lCes on the tlipchart Jnd

see if any should be added.

3. Review the final list, asking the participants which sen'ices are J.\"ailable in their communI

ties. Place a check mark next to each one that is available. Ask. the partiCIpants to SJ~ where

the service is provided. but do not write down the location.

EngenderHealth Comprehensive Counseling for Reproductive Heatth-Trainers' \~ar'uai 9

Session 2

Activity D: Discussion (15 minutes)

1. Ask the participants to close their handbooks. Post the f1ipchart, and review the definitionof integrated SRH counseling.

2. Ask the following key questions:

* What are integrated SRH services?

* How does integrated SRH counseling differ from integrated SRH services?

* Where can integrated SRH counseling be provided?

3. After a brief discussion, ask the participants to open their handbooks to page 9 and ask forvolunteers to read aloud the bulleled points under" How Does Integrated SRH CounselingRelate to Integrated SRH Services""

4. Summarize the session by asking participants:

* Why is it important to understand the differences between these terms?

* How can integrated SRH counseling help them avoid missing opportunities to helpclients in their service-delivery setting?

-+ Training Tip

• "Integrated" SRH counseling ret1ecls the fact that one's sexuo.land reproductive life is not separated into unrelated units of contraception, disease prevention and treatment, reproduction, andexperience with intimacy and pleasure. For individuals and couples, all of these elements are woven together into sexual andsocial relationships, interactions, and consequences-personal,medical, and sociaL Since these issues are integrated in theclient's life, it makes sense to provide information about them inan integrated manner when clients seek SRH services.

• In an integrated approach, we attempt to identify these issues ina comprehensive assessment of the individual's SRH status andconcerns. regardless of the reason for the visit. In many cases,subsequent visits will have to be scheduled or referrals will haveto be made to other service sites. The most important thing,though, is that the client's needs have been identified andaddressed in some concrete and comprehensive way.

10 Comprehensive Counseling for Reproductive Health-Trainers' Manual EngenderHealth

Session 3Why Address Sexuality?

Objectives

• To explain how the quality of integrated SRH counseling and services can he improved byincluding a focus on sexuality issues and concerns

• To describe barriers or challenges for providers in addressing sexuality In integrated SRHcounseling

• To identify strategies for helping providers feel more comfortable ahout and he ~1ter

equipped to address issues related to sexuality and sexual health

Materials


Advance Preparation

I. Read Session 3 in the Participant's Handbook (page II) to review the key di~cLh~lon point:'to be covered.

2. Review Trainers' Options (page 13) to consider alternative \\'ays to conduct (hl~ ,e,,:,it1ll'~

activity.

3, Prepare three flipcharts \vith a heading for each of the discussion topics-"Why is it Important to address sexuality as a part of integrated SRH counseling'~" (Activity A I: "What harriersor challenges might providers experience in discussing sexuality l""ues with c!Jenh'1"(Activity B): and "What can providers do to feel more comfortable and r.ctter equip~d toaddress issues related to sexualityT (Activity 0,

Time

45 minutes Training Activities

A. Brainstorm/discussion .

B. Brainstorm/discussion .. " ,

Time

15 min.

.... , . 15 min.

C. Brainstorm/discussion .. ,....................... 10 min.

0, Summary , .. ,................ . 5 min.

iVote: This session is adapted from: EngenderHeatth. 2002

EngenderHeallh Comprehensive Counseling for ReproductIve Health-TraIners' Manual 11

Session 3


Activity A: Brainstorm/discussion (15 minutes)

1. Lead a large-group brainstorm on the following question: "Why is it important to addresssexuality as a part of integrated SRH counseling?"

2. List the participants' ideas on the prepared flipcharl. Ask leading questions, as necessary, tomake sure that the main ideas from the Participant's Handbook are identified and discussedby the group.

Activity B: Brainstorm/discussion (15 minutes)

1. Despite all of the benefits of addressing sexuality within integrated SRH counseling, it canoften be difficult for providers to introduce the subjCd with clients. Brainstorm and discussthe following question: "What barriers or challenge.'; might providers experience in discussing sexuality issues with clients?"

2. List the participants' ideas on the prepared flipchart. Ask leading questions, as necessary, tomake sure that the main ideas from the handbook are identified and discussed by the group.

Activity C: Brainstorm/discussion (10 minutes)

1. Lead a large-group brainstorm on the following question: "What can providers do to feelmore comfortable and better equipped to address issues related to sexuality?"

2. List the participants' ideas on the prepared flipcharl. Ask leading questions, as necessary, tomake sure that the main ideas from the handbook arc identified and discussed by the group.

Activity 0: Summary (5 minutes)

1. Ask the participants to summarize what they have learned about each of the three discusSIOn areas.

2. Add your own comments to be sure that the Essential Ideas given in the Participant'sHandbook (page 11) have been covered.

12 Comprehensive Counseling for Reproductive Heallh-Trainers' Manual EngenderHealth

Session 3

Trainers' Options

There are several additional ways to conduct thIS activity.

Option 1Set up a "message" or "graffiti" wall. in which the participant;, write their respons6 l~n

large pieces of paper that are posted throughout the room. The steps are as follows:

Preparation1. Create three large banners by taping together three or four tlipcharts horizontally.

2. At the top of each banner. write one of the follOWing questions:

• Why' is it important to address sexuality as a part of integrated SRH eoun~clinf'

• \Vhat barriers or challenges might providers experience in disclbsinf sc.\u.dit:- h:-UC'

with clients?

• How can providers feel more comfortable and better equirred to addre', i"~lC'

related to sexuality?

3. Post each banner on the \\·all.

Large-group exercise

1. Distribute markers to the participants and encourage them to walk around and :-t,lp .it

each banner to contribute either a written phrase. a slogan. or a picture in rC"pl)rh(' t,)

each of the questions posed on the "message wall."

2. Encourage the participants to write on any part of the hanner. in any clireclIon or .lngJe:it is not necessary to line up the responses as a list.

Viewing

I. Once all of the participants ha\'e contributed something to each banner. rccon\-enc thegroup in front of the banners. Ask them to take a few moments to \"iew cac h h:.ll1ncr. [l~

see what the others have written or dra\\n.

2. Facilitate a discussion based on the key di"cu:,sion points gi\"cn 111 the Parti(ir~m("

Handbook.

Option 2Split the participants into three groups and assign one of the questions to each group. !Ifthe number of participants is large-i.e .. more than IS-split them into six group" andassign each question to two groups.) Allot 15 minutes for members to brainstorm theiranswers and list them on a tlipchart. then spend 20 minutes in plenary di~us"lOns. \\lIheach group reporting. Save 5 minutes for a summary.

EngenderHealth Comprehensive Counseling for Reproductive Heal~h-Tra'1ers '.~a'1:.;ai 13

Session 4The Problem Tree

Roots and Consequences of SRH Problems

Objectives

• To identify the causes and consequences of at least three SRH problem"

• To describe the provider's role in addressing the causes and consequence"' pf SRH problems

Materials

• Flipchart paper. markers. and tape

Advance Preparation

1. Re\'ie\\' Ses:-.ion -+ in the Participant's I1andbl)l)k (page 151,

2. Review pages xxi to xxiii in the Introduction for the Trainers about uSing the problem treesand client profiles to adapt this course to the specific needs of the panlL'lr~lr;h,

3, Identify the kinds of SRH problems and client population group~ t() ~ adJre,,~ed in thistraining, based on earlier discussions with klt.:-al program plannch .mel \'. itll the .:,jmii1htr,itl)r~

who requested or approved the training. The client protlleS (Session 61 ,h"uld retlect thesepredetennined needs. Since the client profiles are based on the problem trec~ elcvdoIXd In

this session. be prepared to guide the brainstorming of prohlems in :\cti\'ity :\. !i.) ensure thatthe list includes the SRH needs and client groups that haw been identIfied fN this training

4. Prepare a sample "problem tree" tlipchart. Taping t\.... o tlipchart "heelS together may behelpful. to create enough space for the drawing and to ensure that the writing can ~ seen

by all participants. Draw a large tree tnll1k in the middle. with nUIllCfl1lh rllnh rillin~ thebottom of the page and \vith hranches filling the top. C~e a difft'rcnt co["n:J l11.lrkcr f,'feach section. Refer to the sample "tree" provided on page 17 to fill in the prohlcm. root

causes. and consequences.

5. Post the fl ipchart sheet with the list of SRH sen'ices (from Session .2. :\ct i\ ity C I \\here ;.illparticipants can see it.

Time

I hour Training Activities Time

A. Brainstorm ' , , , , , .... , . , , . ' . , , , .. 10 min,

B. Presentation , , ' , , . , , , , , , 5 min,

C. Small-group work .. , , , ' , , .. , , .. , , . , , , " ,."" 20 min,

D. Plenary.", , ' , . ' , .. , , , , ' , , 15 min.

E. Discussion , , , , , , .. , , , ' , , .... ' , , , , , , , ' . 10 min.

,Vote: The content of thi, ses,ion is adapted from IlED. 2000

EngenderHealth

prEVIOUS PAGE BLANK

Comprehensive Counseling for Reproductive Health-Trainers' Manual 15

Session 4

Trainers' Tool

Sample SRH Problem Tree: HIV/STI communications

,.,,/_f

"

\.Brolcenl

t" ,; . fal'Vliliefi.'1 .7' ~ .. :?_'j",':.~t~-... ~ ;}~:-~

t k,;~-'-'" ./

"

I"i q, \;.,= .....-F~..:'· -, //" '-B I f

,;·,~".~Or

"".;,..f"

~" '.t ,

i "-.. '~ !, 'il J

Prof>(e~:•~ ~ .:',j I ~ ,

! c\ €

!j \ t PeolJ(e wjth HIV'i ST1l ! 'a or an are

/ " ,~

reluctant to let;--~,

j' ;" thei,. "al"tn ers: know.>' 'i_

.vote: The Participant's Handbook has ,:mother cxamrle. for maternal health.

EngenderHealth Comprehensive Counseling tor Reproductive Heaith-Trainers' '.~a"ual 17

Session 5Supporting Clients'

Informed and Voluntary Decision Making

Objectives

• To explain the relationship betwecn human rights and informed and \'oluntary deci5'ionmaking.

• To name three scxual and reproductive rights recognized by international con\cntion~• To describe how sexual and reproducti\'e rights apply to specific health needs and Sef\Ke~ in

the particpants' country

• To define informed and \'olulltary decisioll making. and disti ngui,h It from informedconsent

• To identify at least one example of an infomlcd and \'o]untaf\' deci'lOn that J .:-!lent c~mmake in each SRH service area

• To describe three levels of factors that intluencc lllformed and \'oluntaf\ de.:i'J()D makingfor SRH clients

Materials

• Overhead projector

• Transparencies and notes pages (see Appendix C)

Advance Preparation1. Review Session 5 in the Participant's Handbook (pagc 17L Consider if or how you \\Jnt to

use the Participant \Vorksheet for this session (sec i\"0[<.' [0 Trainer,. r;qce 51.2. Review the transparencies and notes pages on "Promoting Informed and Yoluntary DcChil)n

Making to Support Clients' Rights and Address Clients' .\iceds" (Appendix C. pa.;e 19':: I.and prepare a presentation. (See Activity A. or the Trainers' Option..,. page 22.1

3. Identify any official statements from the country in which the training IS being conductedabout rights that apply to SRH. and incorporate these into the presenlation.

4. Identify local program and sen'ice-delivery guidelines relating to sexual and reproducli\'crights and to informed and voluntary decision making. and incorporate these inlO thepresentation.

5. Make transparencies based on the master copies appearing in Appendix C. or prepareflipcharts as visual guides to Activity A (or the Trainers' Options. page 221.

6. Set up the overhead projector for the transparencies.7. Prepare a tlipchart with the small-group questions for Activity B.

EngenderHealth

FPr-VIOUS PAGE BLANK

ComprehenSive Counseling for ReprodUC[IVe Health-Trainers Manual 19

Session 5

Time

1 hour T~~~gA~vW~TIme

A. Presentation 20 min.

B. Small-group work _ 15 min.

C. Plenary presentation. . . . . . . 15 min.

D. Discussion _. 10 min.

20 Comprehensive Counseling for Reproductive Health-Trainers' Manua' EngenderHealth

Session 5


Activity A: Presentation (20 minutes)Show overhead transparencies to give an O\-en-iew of sexual and reproducti\'c righh and (1finfonned and voluntary decision making. (Cse slides l. -t 5. 6.7.8.12.1-+.1:'1.16. and:lfrom Appendix C. page 191.)

Activity 8: Small-group work (15 minutes)I. Divide the participants into five groups: assign each group one area of 5RH leg.. .:hlXh('

from among family planning: maternal health: 5Tb. HIV and :'dDS: po:--tahortwn ...·~lrc:men's SRH services: and adolescents' SRH sen'ices).

... Training Tip

These em be the same fin:' group, from 5t".;sion -+ (The pfClbIcmTree). and you can assign them the SRH area that they worked l)flfor their problem trees.

In the next session. the groups will develop client profiles hased lmthe problem trees and on considerdtion of the decl~ion, Ihat Inindividual would need to make regarding this problem. Keepll1gthe same ~mall groups for all three ,e..'.siul1" ISe",ion, -+ tu 61 \~l)LllJaHa\',' participants to build on Iheir discussions from one _.'es,ion Il)the next in tenus of specific SRH problems and specific c!lent,'concerns.

2. Post the flipchart and ask each group to answer these questions ahoLlt their arca of SRH* What are the decisions that indi\'iduals male rcganJing this area ()f SRH)* \Vhat are the key se.xual and rcproc!ucIl\e right.s needed 10 'uppon peorle Jrl I:l.1J...:ln,::these decisions?

* Which of these rights are supported in your program or community) Which arc rWI'

Activity C: Plenary presentation (15 minutes)Have each small group present its findings. with brief discussion for clarificatIon or commenh(3 minutes per group).

Activity 0: Discussion (10 minutes)Ask the participants:

* What can we do, as service providers and as citizens. to strengthen sC.xual and reproductive rights so as to support infonned and \'GIuntaI)' SRH decision making"

EngenderHealth Comprehensive Counseling for Reproductive Health-T~a'''ers '.'a'-".)a! 21

Session 5

Trainers' Options

An alternative way to conduct this exercise is to offer the entire presentation from

Appendix C (page 191), with discussion, as follows:

Presentation (10 minutes)

Show the transparencies on sexual and reproductive rights (slides 1 to 6).

Discussion (10 minutes)

1. Ask the participants which rights they are aware of in their own country that apply to

SRH issues. If you were able to identify an official i;tatement about rights, present that

information after a brief discussion by the participarl1s.

2. Ask the participants which rights they believe would be most important to help individ

uals achieve SRH in their own country or community. List responses on the left-hand

side of a flipchart, under the heading "Key S&R Rights."

3. Ask the participants what challenges exist for individuals in exercising those rights. List

the barriers that they identify on the right-hand side of the f1ipchart, under the heading

"Barriers."

Presentation (25 minutes)

Show the transparencies on informed and voluntary decision making (slides 7 to 21).

Discussion (15 minutes)

1. Ask the participants:

* Can individuals make infonned and volunta!)' decisions in each of the SRH areas

covered in this workshop?

2. Explore differences of opinion among the participants. In any given area of SRH, some

individuals are better able to make informed choice': than others. Ask the participants:

* Which individuals can make informed choices? Which ones cannot, and why?


* What can we do. as service providers and as citizens, to strengthen sexual and repro

ductive rights, and support informed and voluntary SRH decision making?


Session 6Client Profiles for Sexual and

Reproductive Health Decision Making

Objectives

• To develop "c1ient profiles" that reflect each of the SRH-rclated topics to he addre,,~ed inthis training and the variety of hackgrounds. needs. and concerns that clienh pre~ent

• To identify the decisions that their "clients" will need to make (based on their definedneeds. concerns. and characteristics l. the information that those clients will need if [hey areto make these decisions. and the emotional Issues raised by their s!tuatlOn"

Materials

• Flipchart paper and markers for five groups

Advance PreparationI. Review Session 6 in the Participant's Handbook (page 23). Con"ider lf or how you \\~lnt to

use the Participant Worksheet for this session (see :'\otc to Tramers. page )1.2. Prepare two flipcharts with the guidelines for devdoping client profiles. as follo\\:-:

Client Profile Guidelines: Part I

Demographic and social characteristics:

• Name

• Age• Marital status• Parity

• Income• Educational level• Social background

Client Profile Guidelines: Part II

Questtons to answer about your cl:ent:

• What are the client's current SRHneeds? What led to them? Who else isaffected by thiS situation?

• What decisions will he or she have tomake concerning this SRH problem?Who else will be Involved in thedeCision making?

• Is your client comfortable with seekingservices for thiS situation? Wherewould he or she go?

• What information will the client need tomake those deciSions, and where canhe or she get that information?

• How does the client feel about thissituation? What concerns or worriesdoes he or she have?

EngenderHealth Comprehensive Counseling for Reproductive Health--Trainers' Manual 23

Session 6

3. Review pages xxi to xxiIi in the Introduction for the Tramers about using the problem trees

and client profiles to adapt this course to the specific needs of the participants.

4. Post the problem tree flipcharts in places around the mom (or in break-out rooms) where

small groups can gather and work around them.

Time


A. Small-group work _ 35 min.

B. Plenary discussion _ 25 min.

24 Comprehensive Counseling lor Reproductive Health-Trainers' Manual EngenderHealth

Session 6


Activity A: Small-group work (35 minutes)1. Explain to the participants that. to consider the individual\ decision-making procc~~ !\)f a

range of SRH needs and services. they will first dc\'e!op "client profiles'" These \\111 ~ indepth. detailed descriptions of typical c1ienh. in each of the SRH areas that arc bClnfaddressed by this training, Although it is not possible to represent aery type of client. thl'exercise will focus on trying to get a broad representation of the b~lCkground", neeJ" ;,lnJconcerns of clients. The profiles will be used as case studies in ',orne ses~i0n-. and !\)[ rpkplays in others.

JH> Training Tip

The client profiles pro\'ide the foundation for keeping the foell' ofthe training on the client's perspective, They should repre~ent rherange of sen'ices to be addressed in this training. plus the \'aricty ofclients (in terms of background. needs. and concerns, that pro\ldcbmay expect to encounter. It would be quicker for you to prepareclient profiles in aJ\'allCe or to prl)\ ide a group of pro!ik~ fn>lllwhich particpants could choose. Howc\·er. the approach u"ec! hereis much more effective. because the participants them~ehc-. h~l\cinput and feel "ownership" for the clients with whom they will be"\vorking" for the rest of the trainin?, Basing these rrntllc~ Con theproblem trees also tailofs the issues to the unique need.... conditlon~.and concerns of different communities and cultures,

2. Refer back to the problem trees, Split the participants into the same five group~. and P\ceach group several sheets of tlipchart paper and markers.

3. Explain that each group is to imagine a real person who has this particular pronkm andshould describe that person and his or her situation. They are to ere.lle a '"chen! rn)!i1c,'"\vhich is like a case study. Ask the participants to work in their small grllur' h) JC\cj,\I' thedetails about their client. reminding them that this indi\'idual may not ha\c ~Ullfht SRH -.ervices yet and thus technically may not yet be a "client" (see Training Tlr ~Io\\' I, Ca,c 'lUdies should present problems but not solutions. Likewise. these client profile ... "hl1ulJ pre,entthe problem and the situation. but not the outcome,

4, Post the tlipcharts entitled "Client Profile Guiddines: Part I and Part II.'" :'I,-.k the partlcl-

~ Training Tip

Although we call these client profiles. the participants may need 10address population groups that for whate\'er n~asons do not acces ..services and thus are never seen as clients. Such groups includeunmarried adolescents. men. minority groups. people who do norspeak the dominant language. refugees. sex workers. homo"cxual".and people who are HIV-positivc.

EngenderHealth Comprehensive Counseling for Reproductive Heailh-TralO\ers Manual 25

Session 6

4. Post the flipcharts entitled "Client Profile Guidelines: Part I and Part II." Ask the partici

pants to follow the guidelines to describe their client in each of these areas. Instruct the

groups to choose someone from the group to write the information about the client on the

flipchart. Explain that they will have 30 minutes, but that, because these are big questions,

they could take a lot of time to discuss. Thus, they should strive to provide basic answers to

these questions; there will be more time later in the \vorkshop to learn more about each

client..---------~--

---------_.._...~--------....,

~ Training Tip

To maintain consistency between profiles and to outline the range of

issues to be addressed, guidelines are provided for developing these

profiles. However, not all issues have to be covered in these initial

profiles. Later in the training (e.g., prior to counseling practice),

"new developments" can be announced for each client, introducing

some change in his or her physical, economic, social, or emotional

condition. These new developments can he used to help the partici

pants focus on issues that they may have been reluctant to bring out

in the initial profiles and to raise the problem of missed opportuni

ties by making sure that the client has more than one SRH problem

that needs to be addressed.

._----_.__.

5. Move among the groups to make sure they do not spend too much time on anyone point,

but that they get some ideas on each one.

Activity B: Plenary discussion (25 minutes)

Invite each group's reporter to share the group's client profile with the rest of the participants.

After each group has presented, ask if there are any other key decisions that this client might

need to make. If the client group agrees, these can be added to the flipchart. With five groups,

there will be only 4 to 5 minutes per group for reporting and discussion, but allow brief com

ments and discussion, if time permits.

26 Comprehensive Counseling for Reproductive Health-Trainers' Manua I EngenderHealth

Session 7Clients' Rights, Client-Provider Interaction,

and Counseling

Objectives

• To list at least four of the sevcn "rights of clients" and cxplaln how they arrl~ to SRHsenxcs

• To explain how different types of health care workcrs-frontlmc staff. rronders. andadministrators and 5upervisors-can be im'oh'ed in supporting clients' rights

• To define client-pro\'ider illferactioll

• To describe strategies to improve c1ient-prO\idcr Interaction and to support cltent:-." right~more effectively in the clinic setting

• To define counseling

• To explain how' counseling supports clients' right"• To identify specific tasks that need to he carried out In counseling• To explain how various types of staff in the participants' work selling can c,my I1tlt different

counseling tasks

Materials

• Flipchan paper, markers, and tape

Advance Preparation1. Review Session 7 in the Participant's Handbook (page 251 and prepare hrief pre:-cnt,1ti()[1,

for Activities A. E. and F The ParticJpant Workshect \\'111 LX' lIsed in .\cEi\HY B.2, Prepare a Ilipchart sho\ving the seven rights of dient... hee Participant\.; Handbook. page:

26 and 27}. List the rights only. lIot the description. Lea\'e enough room on thc right forthree narrow columns (see Activity B1. but do not add the columns yet.

The Rights of ClientsRights

1, Information2. Access to services3. Informed choice4. Safety of services5. Privacy and confidentiality6. Dignity, comfort, and

expression of opmion7. Continuity of care

EngenderHeallh Comprehensive Counselmg for Reproductive Heatth-Trainers' Manual 27

Session 7

3. Prepare another flipchart for Activities Band C, as follow:;.:

Health Care Workers

• Frontline staff

• Providers

• Administrators/supervisors

Instructions for smal1-grou~Ql~~

Identify whether and how health care

workers in each category can support

each right of clients~or threate'l It.

-------------------_._-_._----.. ------------Time

1 hour, 45 minutes Training Activities

A. Presentation/discussion

Time

............ " ......... "" ..... 15 min.

B. Discussion _ _.. __ _ 10 min.

c. Small-group work _ 15 min.

D. Plenary/discussion _. - _ _.. 15 min.

E. Discussion/presentation _ 20 min.

F. Presentation/discussion _.. _. __ _ 30 min.


Session 7


Activity A: Presentation/discussion (15 minutes)

1. Explain that. having considered the sexual and reproducti\'e rights of indi\'idual" ~mct IH'wthese relate to informed and voluntary decision making. the next step will be to l,)ok n1l)respecifically at the rights of individuals once they decide to heeO!n£' "eliems.·· Thi" rne~m~

that the individual or couple have reached a decision to seck SRH infomlJtion or ,en t..:cs

and have succeeded in finding and getting to a service site. Those are major "tep" 1n \\ hlLhrights play an important role: this session. however. will focus on the right'- that artly l'n.:Cpeople walk through the gate. or door. of the ser;ice site.

2. Ex.plain that the originally. 10 "rights of clients" were established fl)r L.lmlly rLmnll1;clients b,Y the International Planned Parenthood Federation. For ih quality imrr,)\cf11c'ntwork, EngenderHealth has since modified these to seven rights. Post the tlirchart li"tin:; theseven rights.

3. Briefly describe each right shown on the flipchart, Then a,... k the participant-. which n:;ht-. arcparticularly important for each of the SRH service areas (family planning. HI\' and STI ''''1'

vices. maternal health care. postabortion care. men's SRH sen'ices. and adolesccnt ,C[\I;.,'c, I.

Activity B: Discussion (10 minutes)

1. Ask the participants to turn to the worksheet on page 30 in their Part1Clr~lIlt'" Kll1dbul'K.Ask for volunteers to read the bo\.es for the negatin~ interaction. and then fl1[ thc r\h!tl\einteraction.

2. Ask the group. "\Vhich of thc client\; rights were imolved in thcse inleradwn'.'" .Inc! 01'k.

them to explain their answers.

»+ Training Tip

Six of the seven rights are invoh'cd in these interactions: information: access tosen-ices (even though she can physically get to the clinic. the negatl\c ll1ter~h:t1(\n

with staff discourages her from staying: therefore. "aeee,-," i, cficdl\ cl~ cknlcJ '.informed choice (in the negati\'e interaction. she is not gi\'cn the urrmtulllt: tl'

make decisions about sen' ices): prh'acy and confidentiality: dignit~. comfort.and expression of opinion: and continuit~'of care (if she i" not able to ~f'Jll ,ervices. then she is certainly not able to be assured "continUIty",. Tht'- j" ~ll1 c\.ollllpkof how the client's rights can ~ negatively or positiwly affected before the clIentever sees a provider. This ex.ercise is meant to prepare participants fN the ,m311group work (Activity Cl by helping them to think about the impact of nonpro\ IdeI'staff on the client's rights.

If you have time. a follow-up to this exercise would be to a..'.,K: "\\-hat role could anadministrator or supervisor play in thIS situation}" An~m~r: :\dmini'-trator~ ;mdsupervisors are responsible for the physicallayollt and timing of "en icc,. ~b well .1:'

for monitoring the beha\'ior of frontline staff and gIving them feedback on their

interactions \vith clients.

EngenderHealth ComprehenSive Counseling for Reproductive Hea::'t--raners Manual 29

Session 7

Activity C: Small-group work (15 minutes)

1. Post the flipchart entitled "Health Care Workers." (Cover or fold over the "Instructions forsmall-group work.") Briefly describe each type of health care worker (from the Introductionfor the Trainers, page xiii). (5 minutes)

2. Divide the participants into three groups. Assign each group to be providers, frontline staff,or administrators or supervisors. Ask each group to choose a "reporter."

3. Ask each group to take 10 minutes to review the seven lights of clients and identify whetherand how health care workers in their category can support or impede each right.

4. Have the reporter make a list in his or her notes of the rights that the group's health careworkers can int1uence, either positively or negatively.

5. While the groups are working, draw three columns onl he right-hand side of the flipchartentitled "The Rights of C1 ients" and label them as shO\v n below.

..------------_._---_.__._._._._._-------~The Rights of Clients

I--R_i9_h_t_S ---+-.F_r_o_n_t_lin_e_st_~!Tf--~I~O-v __i.d_e_r_S_+-A_d_rn_in_.I_S_u_p_e_r'---l

1. Information

2. Access to services I3. Informed choice I',

4. Safety of services

5. Privacy and confidentiality I

6. Dignity, comfort, and Jexpression of opinion I

,--_7_._c_o_nt_in_u_it_y_O_f_ca_r_e -'-____ _..__.~ .__~~ -'

Activity 0: Plenary/discussion (15 minutes)

1. Facilitate the group reporting by taking one right at a time and asking each group whetherthey have any influence on this right. (This way the focus is more on the rights than on thecategory of health care workers.) Allow for only very brief explanations, since you willhave only 30 seconds per group per right. As the repons arc being given, put a check markin the appropriate column, next to each right that a group can influence. (10 minutes)

Jt+ Training Tip

You should find that each type of health care worker can have someeffect on most, if not all, of the rights of clients. While the reportingmay get repetitive, this is precisely how tbe learning impact of thesession is felt. The participants do not generally expect that frontlinestaff, in particular, would have such an important role to play inclients' rights. They may even be surprised by the role played byadministrators and supervisors, who rarely have direct contact withclients but who have a significant effect in terms of the decisionsthey make about staffing and space allocation.


Session 7

2. Ask the participants to suggest ways in which each group can Impr,)\c their llnr.lct l'TI

clients' rights. List these on a separate tlipchart. (5 mil/lIfeS)

Activity E: Discussion/presentation (20 minutes)

1. Explain that one way of helping health care workers to support the nghh of clients IS toimprove the quality of client-provider interaction and its impact on the client's deClsionmaking process, To compile a list of all of the people with whom the client interach in theclinic setting. ask the participants to close their eyes and imagine themsch-cs as J. cllent.walking up to the clinic or service site where they work. Ask them to think oi all elf the different types of staff that a client sees or talks to as he or she appr04!che, and mCHe, Ihrou~h

the service setting. including guards. drivers, cleaners. and reccpliomsh I anyone \\hc) \\t.")rksat that site with whom a client comes into contact).

2. Ask the participants to open their eyes and list the staff that client-. Ct")me into cont.l.:1 \\llh,trying to get them in sequence as nearly as possihlc. List the participants" re,pon,c.;. on theflipchart.

3. Starting with the first person \\hom a client is likely to encounter. ~bk the parti.:ipant,:

* How can this staff person intluence the client's SRH decision-makinf pr0l:e, .... eJlherpositively or negatively?

4. Continue with the rest of the staff on Ihe list. in the order ill which a L'!Ient \\"(")uld erll.:ounterthem (approximately!.

5. Refer to the section on "Client-Provider Interaction" in the Participant' ... Handp00k. Se~~l~")n

7. page 27. Review the main points. noting the role of frontline qaff in m.lktnf the ..::IiClltfeel comfortable and confident abollt his or her decision to "eek ,enILe, ~It thaI ,lIe

6. Ask the participants what they ha\'e learned from these di"clhsion" t)n the nghh of c:lient.'and on client-provider interaction and how this knowkdge can ~ applied \\ hen they returnto their work sites.

Activity F: Presentation/discussion (30 minutes)

I. Explain that the discussion will no\\' focus on a specific form of c1ienl-prO\lder mteraLti,")n·counseling.


* What does "counseling" mean to you'~ How IS It different from cJient-pro\'iderinteraction?

* What role does counseling play In helping clients to make informed and \olunlar.SRH decisions?

* Which of the rights of clients are addressed through counseling~

3. Refer to the section on counseling in the Participant's Handbook. Session 7. page 28.Review the main points, including the definition of counseling, the responsibilitie.;. or tasbof counseling. and the imporlance of counseling in helping client" [0 make infonned andvoluntary SRH decisions and in supporting clients' rights.

EngenderHealth Comprehensive Counseling for Reproductive He atth-TraIners ,l"fanuai 31

Session 7

»+ Training Tip

This session emphasizes the importance of counseling in supportingclients' rights, since this one intervention can be shown to have asignificant impact on all of the client's rights. Return to this pointwhenever the opportunity arises throughout the remainder of thetraining.


* In your work setting, how could different levels of staff be involved in carrying out thespecific tasks that comprise counseling?

5. Explain that the rest of the training will focus on helping staff to develop the knowledge,attitudes, and skills necessary to offer integrated SRH counseling, with the goals of helpingclients meet their own informational, emotional, and decision-making needs and of supporting clients' rights.


Session 8Counseling Frameworks

Option A: REDI

Note: Option A is intended for participants \I"ho are leaming counseling for the firsl rime, uswell as for those who alread\' use the GATHER model for familY planning counselin\? bw arc\t'illing to consider a difj'erent approach. The REDljiwne\l'ork is designed for inft'grared SRHcounseling and is thils rhe preferred tmining optiof/. HOI\'en'I: GATHER call be lhidptcd for

integrated SRH counseling; Option B is intended for those trainers ur progrum nh;n(I~tTS ',\"i:"prefer to COlltinlle IIsing GATHER. The decisioll on \I"haher to lISe RED! or G.-\ THER ,Iuwld hi'made during the planning phase (~rrhe \l"OrksllOp (see Inrrodilction jill' the Trainers, {Jar;e XIX I.

Objectives

• To describe RED!. a framework for integrated SRH c()un~c1ing

• To identify which elements of this counseling framework the particlpants are ~dread: Jam".which would require morc training. and which would encounter barrier.; at their \\ ork "ite'"

• To explain the importance of applying counseling frameworks to each client's umque "ltU~I

tion

• To explain the importance of addressing the social context for decision maktn:c 1I1 mtegrati..'JSRH counseling

• To describe how integrated SRH counseling supports informed and \olul1tary dcci'l0n making by clients

• [If the participants are already familiar with GATHER.] to identify similaritie~ an~1 (IJiicrcncc ...between REDI and GATHER

Materials


Advance Preparation

I, Review Session 8. Option A. in the Participant's Handbook (page 311.

2, Prepare a tlipchart with the three questions for the REDI tables (Acti\'ity B. Step 1)

3, Prepare four flipcharts. one for each phase of REDI. showing the steps for each phase andincluding columns for checking off the current status of that step (Activity B. Step ~ I.

4, Optional: Prepare a flipchart \vith two columns. Write the four phases of RED! in one column and the six steps of GATHER in the other (Acti\'ity D).

EngenderHealth ComprehenSive Counseling for Reproductive J-ieaith-T,a,ners' Manual 33

Session 8A

----------------_._--_.~--------

Time

55 to 60 minutes(depending onwhether Activity Dis used)

Training Activities Time

A. Introduction 10 min.

B. Small-group work 15 min.

C. Plenary/discussion .. _ 25 min.

D. Discussion (GATHER) [optional] 5 min.

E. Summary 5 min.


Session SA

Session 8, Option A, Detailed Steps

Option A: REDI

Activity A: Introduction (10 minutes)

1. Divide the participants into four groups. (If this requires the participanh to mow. ask themto take their handbooks. notepads, and pencils or pens with them.)

2. Introduce the exercise by telling the participants that they will now examine a frameworkfor integrating family planning, sexuality. HIV and STI prewntion. maternal health care.and postabortion care counseling.

3. Emphasize that in all counseling. the client is more imponant than the frame\HJrk. Duringthe following exercises and discussions. they should keep in mind that framework:- can khelpful to providers in gIving them a stnlcture for talk.ing with the client. so they do notmiss important steps. Howcvcr. the framcwork i:> only good if it allow~ ther:1 te, allenJ (\) theindividual client's unique needs and concerns.

4. Refer the participants to Session 8. Option A. in their handhooks. and a,k them t(, find thesummary description of REDI (page 32 l. Brietl: revicw the pha"c:> anJ :>(Cr:>. :\otc that theREDI framework is designed for integrated SRH coun,eling hec<lu,e:

• It emphasizes the client's responsihility for making a decl"lon and for carrying it LiUL

• It provides guidelines for considering the client's sex.ual relatiomhip:> and sl,,-'ial L'c.... nt('\[

• It addresses the challenges that a client may face in carrying ou[ this deci~ion and offer"skills-development to help cli..:nh 111..:..:t tll..:"c ch~tllcnge:>.

ActiVity B: Small-group work (15 minutes)

1. Post the flipchart with the following questions for small-group work. E:\r1ain that CJL'hgroup will consider one phase of RED!. and answer the questions for each :>tep:

* Which steps are you already doing in your counseling')

* Which steps would require further training. whether for knowledge. for skill-.. c.... r f\)rmaking providers more comfortahle') (Further trainmg might ;.thc.... he Cc\IbIJeft'J ll,t'lui

for steps that they are already doing. f

* Which steps would be difficult to implement. and why")

2. Assign one phase of REDI to each group. and distrihute the "cparatc pn:pared tlip-:hartsheets accordingly (see page 361.

3. Ask the participants to refer to the more detailed wrsion of REDI in their handhook" i page"33 to 36) for a better understanding of each step.

4. Explain to the participants that for each step. they should review the descriptIOn In the

handbook, consider these questions. and check any hmes in the table that apply to theirwork setting. It is possible that they may check marc than one box-or all three hoxe:>-forsome steps. If there are different opinions within the group. put a question mark in thc [>0\.

5. Ask each group to choose one member to fill in the table for their group.

6. Give the groups 10 minutes to complete their tables. Check each group quickly to en:>UfC

EngenderHealth Comprehensive Counseling for ReproductIve Health-Tra'~ers' ',!anuai 35

Session 8A

that they understand the instructions. If some groups finish earlier, they can go on to otherphases of REDI and discuss their answers to those qucstwns among themselves.

Rapport-building Already doing

1. Welcome the client

2. Make introductions"~.

3. Introduce the subject ot sexuality

4. Assure confidentiality"_.

ChallengesNeed training anticipated

--

--

2. Assess the client's knowledgeand~iveinformation, as needed

~~~

3. Assist the client to perceive ordetermine his or her own pregnancy orHIV and 8TI risk

fA Exploration

1. Explore the client's needs, risks,sexual lite, social context, andci rcumstances

Already doing

-Challenges

Need training anticipated

-

-,----

'-"

Decision making Already doing

1. Identify what decisions the clientneeds to make

---

2_ Identify the client's options for eachdecision

._-

3, Weigh the benefits. disadvantages,and consequences of each

--4. Assist the client to make his or

her own realistic decisions--.

Challenges! Need training anticipated

-

-

_.

'-"

Implementing the decision Already doing

1. Make a concrete, specific plan forcarrying out the decision

2. Identify skills that the client will needto carry out the decision

3. Practice skills, as needed, withthe provider's help

4. Make a plan for follow-up

I

ChallengesNeed training anticipated

-~-

._,.

-

_.~-


Session 8A

Activity C: Plenary/discussion (25 minutes)

1. Starting \vith "Rapport-building:' a'ik the group reporter to post the group', tllpchan andexplain the group's findings. If there are question marks. ask for a brief explanation..\1,,0ask for a brief explanation of "challenges:- (10 mil/lites fin (d/ four groups I

2. Ask the participants what they learned from this exerci<;e. (5 minutes)

~ Training Tip

Participants should note that they are already doing many of thesteps of integrated SRH counsding. The steps that they feelneed more training will be addres'ied in this workshop. Anticipatedchallenges may be beyond the scope of this training. Howc\·er. thetrainers can share these antIcipated challenges with participanh·supervisors or program managers i who may he p~u1icip~lling 1I1 thi,workshop or a separate orientation l. and this can become ran (1ftraining follow-up (see Sessions ~O and 31 i.

3. Facilitate a discussion by asking the following: que~tions. (See the Di."cu>;slOn Summa0 Inthe Participant's Handbook [page 36] for possible responses.) (10 mimacs J

* How does this framework ensure that the counseling is client-centered'

* How much time do providers in your facility generally spend counse!lllg cdch client)Do you think this framework helps providers to work within this time frame) D~) yl'llthink providers can save time with this framework" If ye:-. how') If no. why nt)t)

* Why does the framework address the "social context" of clients' decisions 1 • •

* How does this framework ensure a client's informed and \'oluntary deciSion maklll~ 1


Note: This discussion is only necessary ~f the parricipuflts are a/ready/ami/iur Il"lrh GATHER.If the.\' are notfamilia,. \l·ith GATHER. there is no need ro introduce il.

1. Post the fljpchart entitled "Comparing REDI and GATHER" (sec below I.

Comparing REDI and GATHER

A Rapport-building G Greet

A AskiassessE Exploration

T Tell0 Decision making

H Help

Implementing the deciSion E Explain

A Return VISII

EngenderHealth Comprehensive Counseling for Reproductive Heallh-Trainers Manual 37

Session 8A

2. Beginning with "Greet" ask the participants to identify lvhich steps of GATHER correspondto the phases of RED!. Draw lines between the corresponding steps and phases.

Jt+ Training Tip

There are many overlaps between the steps of REDI and GATHER.Rapport-building generally corresponds to Greet, with elements ofAsk!Assess. Exploration incorporates Askl/\ssess and Tell. Decisionmaking includes the Help step and also elements of Ask/Assess andTell. Implementing the decision includes I-1Clp, Explain, and ReturnVisit. Since the counseling process is different for each client, participants may have other ideas about the ovedaps that also are valid.

3. Facilitate a brief discussion by asking the following questions:

* What similarities can you identify between REDI and GATHER? What differences?

4. Note that GATHER can be adapted for integrated SRH counseling, and that the Participant's Handbook includes guidelines for doing that. lliowever, REDI was designed specifically to address the client's comprehensive SRH needs and to focus the counseling processon actions that the client takes. Therefore, REDT is the framework that will be used for thistraining. Keep in mind that the counseling process applies the same skills, attitudes, andknowledge, whether the framework is RED!, GATHER. or something else.

Activity E: Summary (5 minutes)

1. Ask if the participants have any further comments or questions.

2. Note that they will spend the rest of the workshop d(~veloping and practicing counselingskills, addressing the attitudinal challenges for providers in integrated SRH counseling, andidentifying key information needed in each area of sel\' ice delivery.

38 Comprehensive Counseling for ReprOductive Health-Trainers' Manual EngenderHealth

Session 8Counseling Frameworks

Option B: GATHER

Note: Option B is designed for participants U110 already use the GATHER 77!ndt'! forfamily planning and who H'Q!lt to continue using this model for intef.:rated SRH cowlselin\?The decision on H'/zether to lise REDI or GATHER should he made dunnr; rht, planning philSt'of the }l'OrksllOp (see Introduction for the Trainen, page xix)

Objectives

• To incorporate sexuality. HIV and STI prevention. po~tahortion care. and m~l!cmal healthcare into the GATHER counseling framework

• To explain the importance of applying counseling frameworks to each client', llntqU(' ~itua

tion

• To explain the importance of addressing the social context for deciSIOn making In IntegratedSRH counseling

• To describe hmv integrated SRH counseling supports informed and \()lllntar~ dec!'lon ma.k~

ing by clients

Materials

• Flipchart paper and markers

Advance Preparation

1. This exercise is intended specifically for the participants who cllrrentl~ u,e the G.-\THERmethod for their work in family planning: if the participants do not lhe G.-\THER. thh e\er

cise is not appropriate. Discuss this issue with program planners and participanh ah~Jd oftime. to determine if the participants have already hcen trained in GATHER.

2. Prepare a tlipchart with the GATHER model written out (Acti\'jty A. Step I J.

3. Review Session 8. Option B. in the Participant's Handbook {page 37 J.

Time

Small-group work

Plenary/discussion

I hour Training Activities

A. Introduction .

B.

C.

D. Presentation/discussion

Time

.5 min

... 20 min.

. 20 min

....................... 15 mm.

EngenderH ealth Comprehensive Counseling tor Reproductive Health-Trainers Manuai 39

Session 88

Session 8, Option B, Detailed Steps

Option B: GATHER


1. Reintroduce the steps of GATHER for family planning and go over them with the participants, referring to the steps on the flipchart (see below).

.-----------_._----_.._-~~-----------,

G GREET the client politely and warmly.

A ASK the client about himself or herself.

T TELL the client about the clinic and about familyplanning methods.

H HELP the client make a decision that is best for him or her.

E EXPLAIN (the method or treatment, or any other relevant issue).

R Schedule a RETURN visit.

2. Explain that in this exercise they will be thinking about how to incorporate a broader definition of SRH into GATHER~specifically, about how to incorporate sexuality, HIV and STIprevention, postabortion care. and maternal health carc into the steps of GATHER.

Activity 8: Small-group work (20 minutes)

1. Divide the participants into six small groups.

2. Distribute flipchart paper and markers to each group.

3. Assign one step of GATHER to each group, and explain that each group will have 20 minutes to brainstorm about how to incorporate sexuality concerns, HIV and STI prevention,postabortion care, and maternal health care, as well as family planning, into its step. Onegroup member is to list the ideas on the flipchart.

Activity C: Plenary/discussion (20 minutes)Invite each group to present to the larger group its suggestions for expanding a particular stepof GATHER to address sexuality, HIV and STI prevention, postabortion care, and maternalhealth care, as well as family planning.

Activity 0: Presentation/discussion (15 minutes)

1. Refer the participants to their handbooks, Session 8, Option B, page 37.

2. Review with the participants "The Dual-Protection GATHER Approach," which appears onpage 39 in their handbooks. Explain that this is one ex.ample of how to use GATHER toaddress both family planning and HIV and STI protecti.on in counseling.


Session 88

3. Facilitate a group discussion based on the following key discussion point':

* What do you think of using the GATHER model for integrated SRH coun,c]mg)

* What do you think is the most challenging step in using GATHER for integrated SRHcounseling? What do you think you could do to make it easier")

* In general. when you have used GATHER in the past for family plannmg counseling.have you always followed GATHER in strict order of steps') Ho\\ ha\'e you adapated itto meet different clients' needs ':

* How can GATHER ensure that the counseling is client-centered'')

* How can GATHER address the "soclal context" of clients' decision:,'') Wh! 1" thl'important?

* How can GATHER ensure a client's infom1ed and yo]untary decision maklI1g"

... Training Tip

The GATHER model does not currently include maternal healthcare. The maternal health care component is being developed andwill be available at a later date. However. the participant:-. ~houjJ beencouraged [0 consider this on their own. especially those who"ework contains elements of matcmal h<:>alth ..::ar<:>

EngenderHealth Comprehensive Counseling for Reproductive Hea!th-Trainers' Manual 41

EngenderHeallh

Part II

The Role of Providers' Attitudes in Creatinga Good Climate for Communication

The provider's attitude toward Ihe client i~ a key factc)r in

effective counseling. Yet many rrO\ldCb are rc[c;onally

challenged by the necessity to di"':llS" SRH need:-. belief.;"

and behaviors that may differ from their own. or may han~

difficulties in addreSSIng the"e l:-"UC" wllh par1lcular l~pcS l)f

clients (e.g., unmarried women. ildr1 ]esccnh. 0r menlo The.;,c

training sessions sel the "tage for di"cu"ic'n" 3bout prc1\"lder,,'

attitudes. \·;l!ue" . .Inc] belief" dnJ their imj'.l('t pn -':JiCilt'

discu""ions that will be reinforced throu~hout the trJll1in~

during group work. di"'Clbslon". and wI..: plays,

Comprehensl"ve Counselmg lor Reproductive Heal:h-Trainers' Manual 43

/"i':: \tlOUS PAGE BLANK

Session 9Rapport-Building

Respect, Praise, and Encouragement

Objectives

• To name the four steps of the "rapport-building" phase of REDI (or the mJin purro ...e (1f the"greet" step in GATHER)

• To explain the importance of showing respect for clients

• To describe at least two ways in which providers can show respect for clienb

• To explain how praise and encouragement can help to build rapport hetween prc1\ider, andclients

Materials

• Writing paper

• Fhpchart paper, markers. and lape

Advance Preparation

1. Review Session 9 in the Participant's Handbook (page 43). Consider if or Iww \','U \\J.n! tc'use the Participant Worksheet for this session. {See ?\ote to Trainer.... pJ.ge 5. f

2. Prepare a flipchart with the four steps of "rappon-building:' showing the he;JJin~> \.'T1I:(Activity A. Step I).

3. Prepare a brief explanation of the four steps of Rapport-Building. for :\cti\'ity .-\. Step 1.(The Trainers' Tool. page -+ 7. repeats this phase of REDI for casy reference. I

4. Prepare a flipchart defining praise and encouragement <'-\cti\'ity B. Step ~ '.

Time


A. DIscussion .

Time

... 10 min.

B. DiscussionJIarge-group work. . . . . . . . . . . . . . 15 min.

C. Pairs exercise/discussion. . . . . . . .. . 15 min.

D. Summary............................. . .... 5 min.

EngenderHeaJth

PREVIOUS PAGE BLANKComprehenSIVe Counseling for ReproductIVe Health-Trainers Manual 45

Session 9


Activity A: Discussion (10 minutes)

1. Post the flipchart (see below) showing the four steps of "nlpport-building" and briefly revieweach step. Note that there will be a separate session on Step 3, "Introduce the subject ofsexuality."

Rapport-building


2. Make introductions

3. Introduce the subject of sexuality

4. Assure confidentialityL- ~ .__. . __._J


* What does respect mean to you?

* How do your clients show respect for you? How do yOll show respect for your clients?How is this different from the way in which you sllow respect for other people withwhom you interact?

* What role does respect play in building rapport with dlents? How could respect (or lackof it) affect communications between providers and cl icnts')

Activity B: Discussion/large-group work (15 minutes)

1. Ask the participants the following questions: (They should have their handbooks closedduring this activity.)

* What does praise mean to you? What does encouragement mean to you?

* How could praise and encouragement be useful in building rapport with clients?2. Post the flipchart sheet with the definitions of praise and encouragement (see helow) and

briefly review these, comparing them to the participants' responses.

Praise means the expression of

approval or admiration.

Encouragement means giving

courage, confidence, and hope.

3. Making sure that the participants have their handbooks C[osed, read one of the client's statements from the praise/encouragement chart in Session 9 in the handbook (page 44). Ask theparticipants what kind of response from the provider would show praise or encouragement,then read the response given in the chart and compare it to what the participants offered.

4. Continue with the rest of the client statements and possihle provider responses.


Session 9Activity C: Pairs exercise/discussion (15 minutes)1. Pair each participant with the person sitting next to him or her. Dlstnbule pIece" of \\ ntmg

paper. one sheet to each pair.

2. Ask each pair to think of one "client statement" that could be challengmg for pronder:- torespond to with respect. praise. or encouragement. Write this statement on one :-heet of paperand fold it. Collect the papers. mix them up. and then rcdimihute them randomly.

3. Giye the participants a few moments to read their "client statement" and to discu"" \\iththeir partner what kind of response would show respect. praise. or encouragemenl. If theparticipants got their own statement. ask them to not let anyone else know. hut :-imply J.eI J.:if it came from someone else.

4. Ask one pair at a time to read their "client statement" and theIr response. Ask the group fn[other possible responses that would show respect. praise. or encouragement.

5. Continue until each pair has responded (or as time permits).

Activity 0: Summary (5 minutes)Ask the participants to discuss what they learned from this session and hnw they can aprly itin their work.

Trainers'Tool

Phase 1: Rapport-Building


• Greet the client warmly

• Help the client to feel comfortable and relaxed

2. Make introductions

• Identify the reason for the client's \'isit• Ask general questions. such as name. age. numhcr of children. etc,

3. Introduce the subject of sexuality

• Explain the reasons for asking questions about sexualn)'• Put it in the context of HIV and 5Th. and assure the client that you discl1s~

HIV and STIs with all clients

• Explain that the client does not have to answer all of your questions

4. Assure confidentiality

• Explain the purpose of and the policy on confidentiality• Create an atmosphere of privacy by ensuring that no one can owrhear your

conversation. even if you are not ahle to use a separate room

EngenderHeaJth Comprehensive Counseling for Reproduclive Heal:n---Trainers' Manual 47

Session 10Provider Beliefs and Attitudes

Objectives

• To explain how providers' beliefs and anitudes can affect their interaction ... with ..:-Itent ....both positively and negatively

• To explain the importance of being aware of our own beliefs and attitude". to avoid irnr~''''

ing them on clients or having them become barriers to communication

Materials


Advance Preparation

I. Revie\v Session 10 in the ParticIpant's Handbook (page -1.7)

2, Revie\\" the list of ·'belief" sti.llen1enlS included in the Trainers ~ Tool on r3gc" 53 [() :'()Select seven to use in this exercise. addressing each of the SRH sen ice......·0\ nee! m thl'training (see Training Tip. helow). and decIde in which order to read them, I l"c)ll rn~t:.. wantto write your own. as necessary. to address specific local issues.)

» Training Tip

Sexual and reproducti\'e health includes some of the lllO... t cotmo\'ersial and sensiti\'e topics in most cultures around the w()rl ..l.However. specific issues and conccms dIffer from place j(l rLh.'c,Therefore. it is important for you to read these st;ttelllcnr..; c1fcfull~

ahead of time. Choose only those that are mo-"t re]c\'ant ((1 thebeliefs and attitudes of service providers in your country, Add ntherstatements. if necessary.

Also. these statemenh are listed in no particular order: you \\lli

need to decide \vhich you want to read first. second. and so on

3. Make three large signs reading AGREE. DISAGREE. and l':\'Sl'RE, Post these slgn~ In

three different locations. with space for people to gather near each sign,

4. Arrange the chairs and tables so people can move easily between the signs,

EngenderHealth

PRr:VJOUS Pl\GE BLANK

Comprehensive Counseling for Reproductive Hearth-,ra,ners "-hnual 49

Session 10

Time


A. Introduction.................. . 5 min.

B. Large-group exercise . . . . . . . . .. . 25 min.

C. Discussion................... . _ 15 min.

Note.' This session is adapted from: EngenderHeallh. 2003.

50 Comprehensive Counseling for Reproductive Health--Trainers' Manual EngenderHeallh

Session 10



1. ExplaIn that this exercise is about our individual beliefs and the effecrs that they ma~ ha\e

on our attitudes toward and interactions with clients..-\sk the partIcipant:' what the wordbelief means to them. and then ask how \,·.-e form our beliefs.

2. Ask what are attitudes. and how our beliefs influence our altitude:-.

Activity B: Large-group exercise (25 minutes)

I. Explain that you wiI1lead a group exercise intended to help the partlCipanh examine theirown beliefs about SRH and SRH clients.

2. Read one of the sewn "beliefs" statements chosen from the list on p3.ges 53 to 56. 3.nd 3.skthe participants to decide if they agree with. disagree wl!h. or arc unsure how they feelaboLlt the statement.

3. After they decide. ask them to get up and stand under the "'Jgn I AGREE. DIS.-\GREE. ("If

UNSURE) that best reflects their opinion. Then ask one or two participant' from each group[0 de'>cribe their thinking about thi ...... tah.'lllClll.

4. Repeat this process \vith more of the statements. for as long as timc permits .

... Training Tip

The belief statements are Tlor to he distributed a."> a handout. hecausethe participants. or others who may read the material... bter. mJ.ymisunderstand the intent of this exercise and think that the"e '-latements reflect the beliefs of EngenderHealth and the trainer....

During this exercise. it is important to remind the participants thatthere arc no "right" or "wrong" answers. People respond r~bed 1.:mtheir mvn beliefs. and one purpose pf the excrci ...c i:- to help exploredifferences when they exist. Therefore. remain neurral thwughoutthe exercise and maintain a halance among the different \"iewpointspresented.

For this exercise to be effecti\"c. it is essential for each paniClpant to

decide whether he or she agrees with. disagrees with. or is unsureabout each statement. This will help them to know their own beliefs.Also, when they practice discussing their beliefs in front of others. itwill help raise their J\',;areness of how these beliefs can affect theirinteractions with clients (and with others 1.

To cover a range of issues in the time J\"Jilable. responses will ha\"cto be limited to just two or three per group per statement.

EngenderHealth Comprehensive Counseling for Reproductive Heattt>-Tramers' Manual 51

Session 10

Activity C: Discussion (15 minutes)

1. Ask the participants to return to their seats.

2. Use the following questions to lead a discussion about this exercise:

* Does everyone in the group have the same beliefs, or ar:~ there differences?

* Which statements revealed the widest range of bcliefs 7 What could explain these differences?

* What happens when providers and clients hold differelll beliefs about SRH issues?

* Why is it important for us, as providers, to be aware of our own personal attitudes andbeliefs about SRH issues?

* What can we do, as providers, when our beliefs about a particular SRH issue make usuncomfortable about talking with clients?

52 Comprehensive Counseling for I~eproductive Health-Trainers' Manual EngenderHealth

Session 10

Trainers' Tool

**00 Not Distribute to the Participants" ;

Sexual and Reproductive Health Belief Statements

Gender and Sexuality

1. It is more acceptable for men to have multiple sexual partner;; than for \\pmen £l1 ha\cmultiple sexual partners.

I Parents should not allow their daughters as much sexual freedom ;1" their '()!1'

3. It is more acceptable for a man to ha\·e an extramarital scxll~d rartner th:m f,)r :l \l, \.'Hun4. It is acceptable for parenh to encourage their sons to haw sex bdl)re m:!I7:.1;~'

5. It is the man' s responsibility to hring the condom.6. :vlost women who gel STb are promi"cllouS.

7. The a\cragc woman walll:- "cx lc"" often than the ah'r:lbc mall.8. Women should be \'irgins when they marry.

9. ~Jen enjoy sex without love morc than women do.10. If a woman never experiences childhirth. she is Ie ... s of a woman.1I. A man is more of a "man" once he has fathered a child.12. There is no stich thing :1' rare in marriage.13..\Ien han~ a right to extramarital scx if their \\ivcs are not "exllal]y J\:llLlbk14. Polygamy protects women from being harassed by their hu"hand, fl)r I1ll1re ,n.15. Women arc incapable of sexual plea"ure without a man.16. A woman who suspects that her hu"band ha" an STI or HI\' h:1' the rJ~ht I(l :-cf.l'c tll

have sex with him.

HIVIA IDS

17. People who do not u"e condoms can only hlame lhemseln~s for gellln:z HI\·18. Health care pw\'iders ha\T the right to know the HIV ,tatus of their cllcnr~.

19. A woman who knows that she i" infected with HIV "hnuld not ha\c :1 h~lh\.

20. People with HIV "hauld not ha\'c se:\.21. It is a crime for people who arc infected with HI\' to ha\e scxual rcJati,m, \\ lthout

informing their partner.

" People who gel HIV through sex deserw it Occause of the beha\'ior~ that they rr.1LtlCe.23. The gm·emment is dOing an adequate joh of responding to the need, clf rcork with

HIY.

24. Life is hopeless and not worth li\ing: if you hi.l\c .-\IDS

EngenderHealth Comprehensive Counseling for Reproduct":e Heal:~-T'aners ~.\a:"Jal 53

____"' ...,~:ri......_~_..._b'......._'~ ..... +.

Session 10

Trainers' Tool

I**00 Not Distribute to the partici~~~tS** ,

Sexual and Reproductive Health Belief Statements (continued)

HIVIA IDS (continued)

25. People with AIDS should be isolated from the rest of tbe community.

26. AIDS is mostly a problem of prostitutes.

27. Health care providers who are HIY-positive have a moral obligation to resign from

their jobs.

28. If a health care provider is tHY-positive, those who wert: with him or her should have

the option to change their schedule if they are no longer comfortable working under those

circumstances.

Sexual Behavior

29. It is acceptable for people of the same sex to have sex '.Ii itb each other.

30. Homosexuals can change if they really want to.

31. Anal sex is normal behavior.

32. Sex without intercourse is not real sex.

33. To be "good," sex must end in orgasm.

34. It is acceptable for someone to have more than one sexual partner at the same time.

35. It should be recommended that couples not many until they have had sexual

intercourse.

36. Prostitutes provide a useful service.

37. Oral sex is wrong.

38. Men who use prostitutes are socially and sexually inackqlJate.

39. If people go too long without sex, it is bad for them.

40. The purpose of having sex is to show love for someone.

41. Any sexual behavior between two consenting adults i~, acceptable,

42. A person can lead a perfectly satisfying life while being celibate.

43. Celibacy goes against human nature.

Condoms

44. Condoms should be distributed to secondary school students who request them.

45. Condom use is a sign of caring and not distrust.

46. Condoms ruin the enjoyment of sex.(continued)


Session 10

Trainers' Tool

**00 Not Distribute to the Participants** .

Sexual and Reproductive Health Belief Statements (continued)

Condoms (continued)

47. Couples can have an enjoyable sex life while usmg condoms e\wy time they hJve :-ex.

48. Educating teenagers about condoms will only encourage them to ha\'c ,ex.

49. If my teenage son asked me for condoms. I would gl\'e them to him.

50. If my teenage daughter asked me for condoms. I would give them to her.

JUdgments about Clients

51. Most uneducated women are incapable of making their o\\n deciSIOns about th('irsexual and reproductive life.

52. If providers are uncomfortable with homosexuality. it is acceptahk for them to referhomosexual clients to other providers.

53. It is hard for me to understand why people wl10 know how HIV is transmilIed WNlld

continue to have unsafe sex.

54. Clients who have good. up-to-date information ~lboLlt HIV [r~ll1"mh:-lDn will makegood choices about keeping themsel\'(~s safe.

55. Clients with two children or more should hi.? sterilized.

Judgments about Postabortion Clients

56. \Vomen who have multiple abortions should be sterilized.

57 Women \\'ho have induced an abortion deserve any pain that occurs during postabortl\.1ntreatment procedures.

STls

58. If people get an STI. it is [heir own fault.

59. Men are [he main source and tran"mirters of STIs.

Adolescents and Young People

60. Our facility should make conrraceptin.' methods available to adole~ccnts.

61. Fourteen is too young for a boy to havc scx.

62. Schools should provide sex education for children before puberty_ qaning J.t age 9 or 10.

63. In most cases. it is not worth discmsing condoms with young people because they willnever usc them.

EngenderHealth ComprehenSive Counseling for Reproductive Heatlh-Trainers Manual 55

Session 10,---~~--------~------------~---~-----------,

Trainers'Tool

I**00 Not Distribute to the partici~;~tS**I

Sexual and Reproductive Health Belief Sta:tements (continued)

Adolescents and Young People (continued)

64. Children should be taught about HIV and other STIs in school.

65. The parent of a teenage client who reports she is having ~ex. has a right to know.

Note: Adapted from: EngendcrHeallh, 2002, Volume I, pp. 70-n.

56 Comprehensive Counseling for Reproductive Health~Trainers' Manual EngenderHealth

Session 11Sexuality

Objectives

• To identify (to themselves) how their personal experiences of "exual de\(~lt'rment andlearning affect their current views and feelings about scxuality is~ue~

• To explain how their own views and feelings about se.\.uality might mtluence their approachto counseling clients on these issues

• (Optional) To lIst four elements of sexuality and describe how they encnmpa.'~ much t,t ourlife experience

• (Optional) To describe milestones in sexual and social development

Materials

• Writing paper. tlipchart paper. markers. and tape

• Guided visualization script (see Trainers' Tool. page 63)

Advance Preparation

Part A. Reflections on How We Learned about Sexuality1. Review' Session II in the Participant's Handbook (page .+9). Consider if or h\")\\ you \\ant t,)

use the Participant Worksheet (Part A) for this session. I See :\otl? to Trainer~. page ~ I.

2. Make sure beforehand that the training room em be closed to oUhidcrs durin:; the guiJeJvisualization exercise.

3. Practice reading the script (see Trainers' Tool. page 63) several time" pll)r w cnnductingthe guided \·isualization. to get a sense for how long 10 p~ithC Pct\\ccn qUC"Ul)I1' and h,'\,many questions to include.

4. For Acti\'ity C, decide whether you want to use large-group di:-cu""ion (Ortit,n I) or "li,,tening pairs" (Option 2) after the guided visualization. Prepare ~l tlipchart \\ith the kc: di,cussion questions for whiche\Tr option you choose (page 60).

Part B. Aspects of Sexuality and Part C. Sexual and Social Development5. Review Session II in the Participant's Handbook (page "+9L The.;;e guideline.;; show how you

can cover both Parts Band C. However. you may decide to presem only on "aspects of sexuality" or only on "sexual and social development": either topic could be expanded into a fullsession of its own. Detennine which option {either B. C. or both. bcq meet:' your participants' needs.

6. Consider if or how you want to use the Participant Work.;;heel (Part C) f(lr thi.;; session

7. If you do Part B. prepare the presentation on "Aspects of Sexualit:."' based on theBackground Materials in the Participant's Handbook (page 52).

EngenderHealth Comprehensive Counseling for Reproductive Hea:th-Tra>ners' Manual 57

Session 11

8. If you do Part C, prepare sheets of writing paper with the milestones listed in "Sexual andSocial Development" in the Participant's Handbook (pages 53 to 54).

9. For Part C, prepare sheets of paper for a time line. On ~;eparate sheets of writing paper,write the numbers 0 .. 5, 10, IS, 20, 30, 40, 50, 60, 70, and go. Post these in sequence on thewall to create the time line.

Time


Part A. Reflections on How We Learned about Sexuality

A. Introduction/instructions 5 min.

B. Guided visualization 10 min.

C. Discussion 15 min.

Part B. Aspects of Sexuality

D. Presentation/discussion 15 min.

Part C. Sexual and Social Deve!opm,.mt

E. Large-group exercise .

F. Summary .

. " 10 min.

. 5 min.

Note: This session is adapted from: EngenderHcalth. 2000; and EngcndcrHealtb, 2002.


Session 11


Part A. Reflections on How We Learned about Sexuality

Activity A: Introduction/instructions (5 minutes)

I. Review the first t\\lO learning objecti\es.

2. Explain to the participants that in this acti\'ity they will spend tIme retlecting. with e~e ...closed. as you read a series of questions that will guide them through mem0fies J.ndthoughts about growing up and learning about sexuality. They will then consider how theseexperiences shaped their own sense of sexu,dity <lnd how tbe:-.c experienL·e ... 111<1\ affect theirwork in counseling.

3. Tell the participants that this exercise is only for them. to think '-lnd r('tlel't for thenb('I\" ....They will not be asked to share their per... onal thoughh or experience ... \\ ltll the LUfLT ,:wlJr.They will sit \\lith their eyes closed. and you \\ill sIX'ak to them for ahpLlt 10 minute .... Durll1~

this time. no one else is to be allowed Into the room. and no one will be wJ.tl'hmg them.

Jt+ Training Tip

:\"0 interruption:-. ... hl)lIIJ he ,dlu\\cJ JuriJl~ rhi ......e ....... illn. \Ltjnt,l1l1li1~

a comfortable. quiet. and pri\ate emiwnment in the training [('0m i...critical to this exercise. Depending on the cultural Cll11lCXt. [he r~l.r

ticipants may feel comfol1able remaining scated or may prefer to hedown as they listen to the script.

4. Ask if anyone has any questions.

5. Ask the participants to make themselves comfortahle and to close their eyes.

Activity 8: Guided visualization (10 minutes)

In a slow. reassuring \'oiee. rcad aillud the scripI bee Tr;J,iner< Tc.('l. P.lfc 6:- l II' Ihe r.::tlL'j

pants. pausing between questions to enabk them to relkc[ on mcmorie ... and ll1ugc".

Jt+ Training Tip

Although we do not ask people to share theIr pcr~onal memories ()rexperiences. this exercise may bring up strong emotions among theparticipants. particularly among those with a history of .sexual ahuseor traumatic expenences. Be prepared to address these issues if they

come up. For eumple. a trainer could watch the group to identif~

anyone who may be ha\ing difficulty with the exercISe and talk to

the person privately. without drawing the attention of [he group. :.mcl

see \\-'hat would make the person more comfortable.

EngenderHealth Comprehensive Counselmg for Reproductive Health-Traine's ~1anual 59

Session 11


Option 1-Large-group discussion (15 minutes):

1. Emphasize that people should not share their personal life experiences, but rather discusshow it felt to think about those experiences.

2. Post the prepared flipehart with the three key questions (see below) and lead a discussion.Do not write the participants' responses on the flipchart.

Reflections on How We Learned about Sexuality

* How did it feel to do this exercise?

* How could this kind of reflection be helpful to your counseling work?

* In what ways does this exercise give you insight into how a client mightfeel about discussing his or her sex life with a heath care provider?

Option 2-Listening pairs (15 minutes):

1. Divide the participants into pairs to discuss how they felt during the guided visualization,sharing only as much as they feel comfortable sharing.

2. After 5 minutes, bring the group back together.

3. Post the prepared flipchart with the three key guestions «;;:~C below) and lead a discussion.Do not write the participants' responses on the flipchart.

Reflections on How We Learned about Sexuality

* How did you feel talking about these issues with another person?

* How could this kind of reflection be helpful to your counseling work?

* In what ways did talking with someone el:3e about the gUided

visualization give you insight into how a client might feel about talking

with a health care provider about the client's sex lite?

,------~~._----~~---~-----_ ..

» Training Tip

If you Will1t to spend more time on the discussion, ask these additional questions:

* Did anything about the exercise make you feel uncomfortable or surprised?

* If the listening pair involves a man and a woman, how did you feel talkingto someone of the opposite sex? How do you think clients would feel in thesame situation?

* Why do you think I asked if anyone had ever assured you that yourthoughts and feelings were norma] and that many people have them?

* How are girls' and boys' experience of sexual development and learningdifferent? Do boys and girls get different messages about their bodies andsex? (If there is only one gender represented in the group, this may be difficult to discuss, as it will be based on assumptioll~.)

60 Comprehensive Counseling for l=1eproduclive Heallh-Trainers' Manual EngenderHeallh

Session 11

Part B. Aspects of Sexuality

Activity 0: Presentation/discussion (15 minutes)

1. Explain that while people often associate the term sexuality with thc tcrm, It'X ~ir,exlwl

intercourse, sexuality encompasses much more than thar.

2. To help the group understand the complnity of sexuality. discu"" four different j'pect" l1fsexuality in a brief lecture.

3. After describing each concept to the participanb. see if they haw any exampie, tli JCI11(.1n

strate their understanding of each element.

4. Facilitate a brief discussion by asking:

* \Vhere is "sexual intercourse" included within the definition of sexLulit\) Dcie, the termplaya large or small role in the definition')

* How does culture Influence the various circles of scxualitv i

* Which aspects of sexuality are very different between males and fcmJ!t:',) Do men anJ

women experience sensuality the same \\<1y') Do men and women \Ie\\ re:atl\in,h:r' the

same \vay"? Do men and women have the same sexual health needs i

~ Training Tip

II This agenda shows how you call. do both ~.~1l1S Band C. IloWL'\lT Y\it). m.l.~

deCide to Include only "aspects ot sexualIty or only "se\ual and "l,,-,[;il ,k\ei

opment": either topic can easily be expanded into a full ,e"i,in ('If it, i'W!1

Review the materials in the Participant's Handbook and determine '.\ hi..:h

option be"t meets your participanh' need:;.

Part C. Sexual and Social Development

Activity E: Large-group exercise (10 minutes)

I. For a fun (and frantic) closing exercise. distribute 16 prepared sheer-; of paper \\nh the ",cxual

and social development" milestones from the Pal1icipant'" I-IalldbcH1K. PCiint \)ut th" ,h;:ct, ,it'

paper (numbered from a to 80) that you posted on the \\aII e~irlier. ExpLul1 ~k\t ttl> ], ~1 timeline. Ask the participants to quickly (in only:) minutes) stand alon~ the tlll1c lmc ,n ,-'l1n';1<)

logical order for each milestone. Expect a lot oi confu~ion. ~()me bunchin; ur, Jnd ~l le\\arguments. This is all part of the learning experience. because there arc \"ery few "ri~ht'"

answers.

2. After 5 minutes, ask the participants to read their mikqones. from the younge"t Ie) thc c)IJest. It is okay for a large group to be bunched together in the age range of =' to I ~ year,: do

not force them to be in a straight line, Thank the participants for their efforts: ask them to

return to their seats. open their handbooks to Session II. and find the "Sexual J,nd Social

Development" section (page 53).

3. :-';ote the earliest dC\'elopment in the list ("hegins to ha\'c sexual re-.pon,c,··' J,nJ see where

that fell in their chronology. ;-..rate the latest development ('"e:i.pcriencc" se:i.uality in bter

life") and see where that fell in their chronology. Briefly ask the following que,tll"n,

* When on the time line does most sexual development occur')

EngenderHealth ComprehenSive Counseling for Reproductive Heaim~Trainers ~.'anual 61

Session 11

* Were you surprised about where any of the cards were placed? Which ones'? Why?

* Which placements would be different for males and females? Which would besimilar?

r-------------------------..~

... Training Tip

Ideally, there will be about 16 participants, which will yield one developmentalmilestone for each participant in the large-group exercise. If there are morethan 16 participants, you can create participant "team s" If there are fewer, thensome of the wider-ranging milestones (e.g., "begins 10 show romantic interest"or "begins to engage in romantic activity") can be left out.

Try to avoid arguments about where these milestones occur. Allow the participants to "bunch up" and not try to put the milestones in linear order. One of thelessons is that some of these milestones vary among individuals and amongcultures.

Activity F: Summary (5 minutes)

Ask the participants:

* How have your thoughts about sexuality changed since the beginning of this session')

* How can you use what you have learned in your work?


Session 11

Trainers'Tool

Guided Visualization Script

Picture yourself as a child and see ~dwt memories come lip as I ask yOIi the followingquestions:

• Reach back into your memories. and picture yourself as a child of 5, What W~L' your Ilfelike then') Who were the important people in y'our life'?

• Remember yourself at age 10. Where did you liw') Who were the important ['('ork :nyour life?

• As you were grow'ing up as a young child. what types of rnes~;J.ge:,> did you rc(ci\c fh'nlother people about touching your own hody')

• \\'hat messages did you rccci\'c about the oppositc se\'.' :\s YOU gre\\ olJer. 110\\

these messages changc'?

• Think about when you first learned where bahic~ come from. How old \\cre yelu' I Ie)\\did you feel about it)

• For women, how did you first learn abOll! men:-lruatiun} Ho\\ old \Vcrl..' \l)l!) Ihl\\ e1:Jyou feel about it?

• For men, how did you first learn about we! dreams (nocturnal emlSslOn ... j) How lliJwere you? How did you feet about ir)

• \Vhen you were 12, how did yOll feel about your hody·.'

• Think back to when you first learned about sex.. Where did you hear abollt it tlr~t} Oldyou talk about it with a parent or an adult. or with a friend')

• Think about the first time you tried to talk to someone about sex.. \\'hat was i! lIke' Hemdid the person respond? How did it make you feel'}

• How did you feel about the idea of having sex. yourself?

• Did you ever have thoughts abour sex Ihat you WIshed you did no! h:l\e~

• Did anyone ever assure you that these thoughts and feelings arc norma] and that I1hhtpeople have them? Do you still worry about these thoughts'}

• Think about your first sexual experience. How did you feel beforehand} How dId \ I)U

feel afterward'? What was the communication with your partner like'}

• How did the messages that other people gave you about sex affect your feelings}

• As you have grown older, have you become more comfortable with "ex'} What hashelped you feel more comfortable'?

When you are read.\: open your eYes.

Note: Adapted from: EngenderHeal!h. 2002. Volume 2, pp 62-66.

EngenderH ealth Comprehensive Counseling for Reproductive Heatth-Tra:ners' Manual 63

Session 12Variations in Sexual Behavior

Objectives

• To identify their own biases and judgments related to various sexual ocha\'ior"

• To recognize differences in individual and cult L1ral perspect i\'es about sex LILlI he havi()r.including differences in what is considered "normal" or "acceptable"

• To explain why it is important to be nonjudgmental about sexual beha\ior:- when c()unseling clients about SRH

• To be more comfortable when discussing a range of sexual bd1a\ior:- with chent:-

Materials

• Large cards or writing paper and scissors

• \:larkers-one for each participant. if possible

• Tape

Advance Preparation

1. Review Session 1.2 in the Participant's Handbooh: (page 57).

2. Re\'iew the list of beha\'iors (see Trainers' Tool. page 701, and sekct 25 to .:.() rCI usc in thissession. Try to get a mixture of behaviors that people would be familiar with and thll:-.C th;)tthey might not. Add new beha\'iors or omit other.;. based on the local "ituaticJn. It i:- lmr()rtant to include some behaviors that are outside of the mainqream or that arc tabclo. ('\en itthese behaviors are not generally acknowledged in the Joc..d .;erring

3. Prepare the behavior cards. Use heavy paper or card stoeh: if available. or "beet" (If lcncrsized paper if not. Write one sexual behavior on each piece of paper. Print USJng a largemarker and large letters, or print the page'> L1,>ing a computer in a large. bold typcfaee ~o thewords can he read from a distance (see e.'\.amplc, below I,

Vaginal Sex

EngenderHeallh Comprehensive Counseling for Reproductive Health-Trainers' Manual 65

PREVIOUS PAGE BLANK

Session 12

4. Prepare three additional sheets, one with the phrase "(I K for me," a second with the phrase"OK for others, but not OK for me," and a third with t he phrase "Not OK" written in largeprint. Use different colors of paper for each of these three sheets, if possible. Post themhigh on the wall, ensuring that there is sufficient space between them to place three to fivevertical columns of cards beneath each.

5. Prior to the exercise, prepare small pieces of tape, enough to affix all of the behavior cardsto the wall.

Time

Time

..................... 5 min.

.. '" _ 15 min.

Training Activities

A. Introduction/instructions

B. Large-group exercise

45 minutes

C. Discussion/summary. . 25 min.

Note: This session is adapted from: EngendcrHcalth, 2002.


Session 12


Activity A: Introduction/instructions (5 minutes)

1. Introduce the exercise by saying that this session will explore the range of -;exual heha\ior.;

that people engage in and the attitudes and values that \ve have about those behavior:-- Ex-r1J.in

that this interactive exercise will allow everyone to examine their own personal \3Ju:.> arL'ut

different sexual behaviors but in a completely confidential way.

2. Tell the participants that you will give each person one or morc cards with a sexual lxh;l\

ior written on it. Instruct them to determine ho\',,' they pehonally fed about the P;lfth.:ubr

behaviors written on their cards and to indicate this by writing one of these phrase:- L,n the

back of the card:

• OKfor me (meaning that it is a behavior I personally would engage in I

• OK for others. bill not for nIl.' (meaning that it is a bcha\'ior I pcrs0n.lll~ \\ \"tllJ I> ':

engage in, but is one that I have no problem with other people doing 1

• Not OK (meaning that it is a behavior no one should engage in becau:--c i: j" l11,x.11ly. ct::l

cally, or legally \\Tong)

3. Remind the participants that this exercise is meant to be completely CO/l'Uol:i,;!, ",' ::-:;:\

should not show the behavior on their card or their response to it to anyone. T" en:--url? ..:,'n

fidentiality. before distributing the cards you may want to ask the participants to reJTLm~C

their seats or spread around the room so that no one can see the other partlcipant"- card:- ,IllJ

responses.

Activity B: Large-group exercise (15 minutes)

1. Distribute the sexual behavior cards (facedown) and one marker each to the paniClr.lnb,

attempting to give each person the same number of cards. until all of the carJ:- h~1\e h-.:cn

distributed. Invite the participants to look at their cards and think about the hehavj('r WrItten

on each.

» Training Tip

Instruct the participants that if someone gets a card with a ~hJ\i0f

that he or she does not understand. he or she should sigml Y0U to

ask for an individual explanation, If the beha\'ior is explained in

front of the group. that will take away the anonymity for that

participant.

2. Repeat what is meant by "OK for me:' "OK for others. hut not for me:' and "not OK:' and

ask if everyone understands.

EngenderHealth Comprehensive Counseling lor ReproductIVe Hea!lh-Trainers Manual 67

Session 12

3. Instruct the participants not to write their names on the cards. Ask them to mark on the backof each card their response to the behavior, without showing their cards to anyone. Whenthey are done, they will place the cards with the behavior facedown in a pile in the center ofthe room (or a trainer can collect them, without looking at the behavior).

~ Training Tip

It is helpful to continually remind the partJc ipants that this exerciseis not about STIIHIV risk, but about values and judgments aroundsexual behaviors in general. Sometimes the participants may havedifficulty separating their ideas about disea~\e risk from their valuejudgments about behaviors,

4. Mix up the cards and redistribute them to the participants, asking them to take as manycards as they put down.

5. Have the participants take turns, one by one, reading aloud each card and then taping theircards on the wall under the appropriate category ("OK I'or me," "OK for others, but not forme," or "Not OK"), according to what is indicated on ttc back of the card. Remind them toput the card in the category that is marked, even if th.:y personally do not agree with it.Encourage them to line (queue) up to read and post their cards, and move quickly one afterthe other.

Activity C: Discussion/summary (25 minutes)1. Once all of the cards have been posted, instruct the participants to gather around the walland to take a few minutes to observe the placement of the cards.2. Facilitate a group discussion based on the questions below. Do not move the cards if there

is disagreement. Simply acknowledge the difference of opinion and leave the cards asthey are.

* Are you surprised by the placement of some of the cards? Which ones surprised youand why?

* How would you feel if someone had placed a beha\' Lor that you engage in yourself inthe "Not OK" category?

* How would you feel if someone placed something you felt was wrong or immoral inone of the "OK" categories?

* How did you feel placing someone else's response card on the wall? Would you havefelt comfortable placing your own responses in front (If the group?* What does this exercise tell us about how clients might feel when providers ask themabout their sexual practices?


~.,.-,------

Session 12

»+- Training Tip

If some participants indicate that a particular sexual practice doe"

not exist in their culture (e.g .. anal sex l. ask other particIpants to

verify whether this is true. Some participants are more aware of \'ari

ations in sexual behavior than others and can help their colleague.;;

understand the range of behaviors.

Do not a.o;k the participants to identify who placed anyone respon"e

in a particular category_ If a participant would lik.e to \'olunteer such

information to explain his or her answer. they may do so, hut to ~l,k

might make the participants uncomfortable and tak.e away the

anonymity of the exercise.

3 Summarize by asking:

* Ho\\! can you apply to your work what you ha\'c learned 111 this ncrci:-e'

EngenderHealth Comprehensive Counseling for Reproduchve Health-Trainers' Manual 69

Session 12

Trainers'Tool

Different Types of Sexual Behaviors

The following behaviors represent a wide range of sexual activities. Trainers should feelfree to add new behaviors or omit some on this list, b,lsed on the local situation. For theaverage-sized group (12 to 15 participants), select 25 to 30 behaviors, to allow enoughtime for discussion. If there is more time (e.g., one hour), you can increase the number ofbehaviors included.

HuggingKissingGiving oral sexReceiving oral sexHaving group sexHaving anal sexHaving sex with someone of the same sexUsing objects or toys during sexGetting paid for sexHaving sex in public placesBeing faithful to one partnerHaving sex with a person who is much

youngerMasturbatingManually stimulating your partner

(using your hand)Having vaginal sexWatching pornographic moviesHaving sex with many partnersHaving sex with people whom you

do not knowInitiating sexual encountersPracticing sadism and masochismSex between a teacher and a studentHaving oral-anal sexEngaging in "dry sex"Sex between a child and an adult relativeHaving sex with someone other

than your spouse (adultery)Agreeing to have sex with someone who

will not take no for an answer

Paying someone for sexHaving premarital sexHaving sex with animals (bestiality)Havmg sex with a relative considered too

close (incest)Swallowing :,emenHaving sex with children (pedophilia)Tel Ii ng sorr,eone a lie just to have sexHaving sex with someone of another race or

ethnicityHaving sex whenever your partner wants itHaving sex v,'ith someone who is marriedHaving sex with a disabled personHaving sex under the influence of dmgs or

alcoholWatching other people have sexSharing sexual fantasies with othersBeing celibateHaving sex in exchange for money to

support your childrenHaving sex without pleasureHaving sex with your spouse because it is

your dutyRapeUsing a vibrator for sexual pleasurePlacing objects in the rectumPlacing obje.:ts in the vaginaPlacing devices on the penis to maintain an

erectionTying up your partnerBeing tied up by your partner


Session 13Building Rapport with Male Clients

and with Adolescent Clients

Objectives

• To describe the special needs and concerns of two types of clients-men and ado!es(:-:nb

• To explain the importance of building rapport immediately with male client' ~md adcI!c:,(:enh

Materials


Advance Preparation

Revie\v Session 13 in the Participant's Handbook I page 59!. particularly [0 prepare fur theminilecture and large-group exercise in Activities Band C and the pre~C'I1tation In Activity E.

Time

1 hour. 15 minutes Training Activities

A. Introduction ....

B. Presentation .

C. Large-group exercise .

O. Discussion .

E. Presentation/discussion .

F. Summary .

Time

5 min.

15 min.

. .. 10 min

. .10 min.

. 30 min.

.5 min.

EngenderHealth Comprehensive Counseling lor Reproductive Heallh-Trainers' Manual 71

Session 13



1. Review the Essential Ideas from the Participant's Handbook, as an introduction to this session. (Participants should have their handbooks closed throughout this discussion.)

2. Explain to the participants that the session's purpose is to help them begin thinking abouthow they could increase their own comfort in talking with men and with adolescent clients.

~ Training Tip

The short amount of time devoted to this lopic is almost a "token"effort, but completely omitting men and adolescents from thecurriculum would be worse. For providers who deal with adolescents and men, additional training is strongly recommended.Exi:;ting curricula and supplementary modules (now being developed) arc cited in the Introduction for the Trainers (page xi).

Activity B: Presentation (15 minutes)

I. Give a minilecture based on the materials in "Understanding Men's Needs and Roles,"found on page 59 of the Participant's Handbook. Begin by asking:

* What are your biggest challenges in providing SRH counseling for men?

2. Involve the participants by using the scenarios, saying what might not work, and then asking a participant to give a better statement or question.

Activity C: Large-group exercise (10 minutes)

Using the table "Sample Phrases to Use When Addressing Men ... " on page 62 of theParticipant's Handbook, read the need or role, and then go around the room, asking eachparticipant to suggest a sample phrase that would be appropriate.


Explain that rapport means "a dose and sympathetic relationship, agreement, or harmony."Having considered men's needs in counseling and their roles in decision making, ask theparticipants:

* What can happen if you do not build rapport quickly with a man who comes to your service site?

* How could building rapport help make SRH services more accessible to men?


Session 13

Activity E: Presentation/discussion (30 minutes)

1. Give a minilecture based on the materials in "SRH Sen·icc:-. and Coun"elin£ forAdolescents:' found on page 63 of the Participant's Handbook. Begin by asking:

* What are your biggest challenges in providing SRH counseling for adolescent,,')

2. Following the minilecture. ask the participants to suggest statements they could make toadolescent clients to "create an atmosphere of pri\·acy. respect. and trust" (lh3t IS. to buildrapport). Write their suggestions on a f1ipchart.

3. Discuss the questions:

* What can happen if you do not build rapport quickly with an adole"cent who come-; to

your service site'?

* How could building rapport help to make SRH sen'ices more acceSSIble to adolescent'"



* How can you use what you haw learned to build rapport with male and 3d(~lescent C!:cnb '

* What else would you like to learn ahout integrated SRH coun"cling for men and aJo!c,-cents?

EngenderHealth Comprehensive Counseling for Reproductive Heallh-Trainers Manual 73

EngenderHealth

Part III

Communication Skills

Good counseling requires good communicJti0n ~k.1Ib. The

abilities to establish rapport. to ehci! infc.rma[[\)n. and w

provide information effectively Jre nece,,~~HY to ,;uPPQrt

clients' informed and voluntary dechion m,tking. To etfectively

assess clients' needs. providers need t() couple 0IX'n-endeJ

questions that encourage clients to talk abllu! them~e1w.; with

active listening skills and effective paraphrJ.:-ing. to en:'Llfe

comprehension. To giw appropriate infprma!ll'!l. provider.;;

must be able to communicate their krc\\\kd,cc ~1b('ut SRH

issues effectively This requires the abilit~ to expLim thing~ in

language and terms the client under:-tanJ." \with N without

the help of visual aidsL and comfort in [alking abllut i~suc.;

related to sexuality. Dev'e loping rappl1r! WJ:- Il1trllJuceJ Il1

Session 9. The training sessions lha! follll\\ intwJuce the

other essential communication skill-..

Comprehensive Counseling for Reproductive Health-Trainers' Manual 75

PP.EVIOUS PAGE BLANK

Session 14Asking Open-Ended Questions

Objectives

• To describe two basic types of questions used when communicating with SRH C]lenh• To explain the importance of open-ended (and feeling/opinion) que"tion" In a~.-;e"~lllgclients' needs and knov, ledge

• To refonnulate closed-ended questions into open-ended questions• To identify open-ended guestions with \vhich to explore sexuality issues related 10 HJ\' andSTI risk. antenatal. postpartum. and family planning concerns. and other SRH b<'UC'

Materials


Advance Preparation1. Revie\v Session 14 in the Participant's Handbook (page 67). The Participant Work...heet Will

be used in Activity D,

2. Prepare at least two tlipcharts for Activity A (page 781.3. Prepare five flipchart sheets for Activity D. with the headings: "Family PlannIng."'"HIV/STI," "Antenatal and Postpartum:' "Postabortion:' and "Sexuality Issue~,"

Time

1 hour, 30 minutes Training Activities

A. Brainstorm " , .

Time

B. Presentation ' 10 mn.C. Large-group work . . .. 20 minD. Small-group work , 20 min,E. Plenary _. _ _.. ' _. . . . . .20 min.F. Discussion/summary _. . . . . . 15 min.

Note: This session is adapted from: EngenderHeallh. 20m.

EngenderHealth Comprehensive Counseling tor ReprodUC!fve Health--Tral:1ers Mal'ual 77

PREVIOUS PAGE BLA"',"/I. ;\

Session 14


Activity A: Brainstorm (5 minutes)


* What is the purpose of asking questions during coun sding?

(Since you will be referring quickly to the Particip3nl.'S Handbook, do not write their

answers on the flipchart.)

2. Post the prepared flipcharts where you can write on them (see below for example of

flipchart).

Questions: Closed or Op'---

C 0 Questions._~--

-_.-

en?

3. Ask the participants to brainstorm questions that typically are asked of SRH clients. Write

each question in the "Questions" column, in full and exactly as it is given by the participant.

Do not stop until you have at least 10 questions.


1. Ask the participants to open their handbooks to Session 14. Discuss the purposes of asking

questions, comparing what is included in the section 'Why Do We Ask Questions... ? (page

67 in the Participant's Handbook) with what they discussed.

2. Then discuss two types of questions·--closed-endcd and open-ended-and the different pur

poses for each type. Review the examples.

Activity C: large-group work (20 minutes)

L Return to the '"Questions" flipchart from the brainstorm. For the first question, ask the par

ticipants, "Is this closed-ended or open-ended?" Place a check mark in the "e" or "0" col

umn. Continue for the rest of the list. (5 minutes)

2. Tally the number of closed-ended and open-ended questions and note the totals on the

flipchart. (In virtually every training, this list will be predominantly closed-ended questions.)


* What can you observe from this brief exercise about the kinds of questions most often

asked in client-provider communications?


Session 14

* Why does this happen?

* What effect would this have on counseling" (10 minutes)

4. Demonstrate how to change a closed-ended question into an open-ended question. thingone from the list. Ask the participants to volunteer to do the same (if po~sible. for the rest.If most of the questions are appropriately closed (e.g .. age, marital statu .. , number of children, or date of last menstrual cycle. among others). ask for more examples of open-endedquestions that would be useful in SRH counseling. List these additional questions on a separate flipchart. (5 minutes)

Activity D: Small-group work (20 minutes)

I. Divide the participants into five groups: gin~ each group marker" and one of the prepJ.r~d

flipcharts.

2. Refer the participants again to Session 14 in their handbooks: a...; ... ign ~aLh group on~ of th~

topic areas from the "Asking Open-Ended Queqions ahollt SRH Concern,," ParticipantWorksheet (pages 69 to 70). Ask each group to:

• Discuss what specific questions would he effective in helping the client to e.xplore theissues listed under their topic area

• Write these questions on the tlipchart

3. Remind them that they should lise open-ended questions as much as possihle. and tell themthey will have 15 minutes to work in their groups.

4. Quickly check with each group to see that they understand their instmctions. Give them atime check after 10 minutes. Stop the groups after 1" minutes. It is Clkay if they ha\'''' nn!covered all of the issues listed in the bullers (especially the fifth group J. ( 15 minute51

Activity E: Plenary (20 minutes)

One at a time, ask each group to post their tlipchart on an easel or wall. Each group will havc4 minutes to present their questions and rcceive feedback from the others. A representati\'c ofeach group will read the list of questions.

Activity F: Discussion/summary (15 minutes)

1. Lead a discussion by asking the participants:

* How well do these questions address the specific issues identified in the worksheet?

* How well did the group make use of open-ended questions')

* What other questions would you suggest"?

* How comfortable do you think a provider would be in asking these questions')

* How comfortable do you think a client would be in answering these questions')

(You may not have time for all of these questions. so concentrate on the first three and dothe last two as time pennits.) (10 minutes)

2. Ask the participants to summarize what they have learned from this session. Add your owncomments, as necessary, to cover the Essential Ideas for this session from [he PartiCipant'.;,Handbook. Ask how they can use in their work what they have learned in this exerci..;c.(5 minutes)

EngenderHealth ComprehenSIve Counseling for Reproductive Heatth-Trainers' Manual 79

Session 15Listening and Paraphrasing

Objectives

• To describe at least two purposes of listening as a key communication skill for coun~('lmg

• To list at least three indicators of effectin~ listening

• To name at least two purposes of paraphrasing in counseling

• To demonstrate paraphrasing

Materials


• Trainers' Tool from Session 10 ("Sexual :.ll1d R~producti\'e Hedlrh Belief Statcment:-"·).pages 53 to 56.

Advance Preparation

1. Review Session 15 in the Participant's Handbook (page 7n Consider if or how YllU want t()use the Participant Worksheet for this session (Sec :\l)te to Tniners. ra:;e :-; 1

2. Prepare a flipchan on "Paraphrasing" (Acti\'ity Bl.

3. Select four statements from the "Sexual and Reproductive Healrh Belief St;Jtl.'ments··(Session 10, pages 53 to 56) that were not used during that session.

Time


A. Demonstration role play/discussion .

Time

B. Presentation 5 min.

C. Small-group work .

O. Discussion .

20 min.

..5 min

EngenderHealth Comprehensive Counseling for Reproductive Health-Trainers' Manual 81

iffRrnOUS PAGE BLA:.,\

Session 15


Activity A: Demonstration role play/discussion (15 minutes)

1. Explain that two trainers will do a demonstration role play of interaction between a clientand a provider. Ask the participants to observe the imeraction, noting nonverbal as well asverbal communications.

2. Have one trainer playa "provider" who is not listening we]] at all, demonstrating the opposite of all of the points of effective listening for this·..ession shown in the handbook (page72). Have the other trainer playa "client" who is trying Lo communicate something important to the "provider."

3. After one minute, stop the role play and begin a second role play, with the same trainers inthe same roles but with the "provider" showing good listening skills.

4. Ask the participants \vhat was different about these two role plays. Ask the participants howthey know when someone is really listening to them. List their responses on a flipchart.

5. Summarize by stating the purposes of listening as a cmnmunication and counseling tool.


I. Post the flipchart on "Paraphrasing" and briet1y review it.

Paraphrasing

Paraphrasing means restating the client's mes~,age simply and in your ownwords.

The purposes of paraphrasing are to:• Make sure you have understood the client correctly

• Let the client know that you are trying to understand his or her basicmessages

• Summarize or clarify what the client is trying to say

2. Demonstrate paraphrasing with a participant or co~trainer, using one of the believestatements.

Activity C: Small-group work (20 minutes)

1. Divide the participants into groups of three each. E:l(plain that they will practice listeningand paraphrasing in their groups three times. Ask them to decide, for this first time, whichperson will be the "speaker," which one will be the "paraphraser," and which one will be the"observer." Note that the roles will change for each practice session.

2. Give the following instructions: "I will read a statement. The 'Speaker' will have 1 minuteto explain why he or she agrees with, disagrees with, or is unsure how he or she feels about


Session 15

that statement. Then the 'paraphraser' will try to restate what the '~~aker" ~<:ud. In hl:-- orher own \vords. Finally, the 'observer' will comment on the listening and paLiphra"mg "killsthat were or were not demonstrated. After that (about 5 minutes total I. you will changeroles, and I will read another statement:'

3. Read aloud one of the statements from among the "Sexual and Reproductln.~ Health BelietStatements" and ask the "speakers" to give their opinion-agree. disagree. or un"urewithin their group. Stop them after I minute. and ask the "paraphrasers" to paraphrase. Stopthem after 1 minute and ask the "observers" to give feedback. (5 minutes rorall

4. Repeat this exercise twice (with different statements). so that each person has had a chanceto practice listening and paraphrasing. (10 minutes)



* What did you learn from this ex.ercise on listening and paraphrasing')

* What was difficult'} What was easy?

* How can you improve your skills'}

* How can you use in your work what you have learned in this session:

EngenderHealth Comprehensive Counseling for Reproductive Heallh-Trainers' Manual 83

Session 16Using Language That Clients Can Understand

Objectives

• To be more comfortable using sexual terminology with clients

• To be able to refer to local words for sexual acts and body parts. to make the link ~t\.. centhe words that the client understands and the word" that the provider is comfcmahk u,in~

• To demonstrate the use of simple language to explain ..;\?Xual and reproducll\c an;lt~)m: andphysiology to clients

Materials


Advance Preparation

1. Revie\v Session 16 in the Participant"; Handbook Ipage 75).

2. Review the Training Tips (Activity A) to decide which headings to LhC for the bn~ua'::l' .lnd

sexuality exercise (Activities A through C) ~il1d ho\\' [0 nr?anize the ,mall-~f(1Llr \\ pr~

3. Prepare at least four two-column tlipchans \\'jth heading:- related to :-exuaJity (hod: pan, ,1rsexual acti\·ities. such as male ..;exual anatomy. female scxual anatomy. ..;c\ual imc'rCl'ur,e[penile-vaginal]. or other sexual behaviors l. l'se one heading per tlipchart. The krt-h.ltll!column should say "medical terms."' and the right-hane! column ~hoLlld ~a\ ··J()(·.d 'lJ.n{·(see example belmv),

Male sexual anatomy

Medical terms

EngenderHealth

PREVIOUS PAGE BU-,

Local slang

ComprehenSIve CounselIng for Reproductive Heaith-Tra,ners '.'anual 85

Session 16

Time

1 hour, 15 minutes Training Activities Time

'" '" . , .. " ., , .. 15 min.

. '" .. , 15 min.

. '" .. 10 min.

Part A. Language and Sexuality

A. Introduction and instructions " 10 min.

B. Small-group exercise " 15 min.

C. Discussion 10 min.

Part B. Using Simple Language

D. Introduction and instructions .

E. Small-group work .

F. Discussion .

Note: The "Language and Sexuality" section of this session is "darted I"mm: EngcnderHeatth, 2002.


Session 16


Part A: Language and Sexuality

Activity A: Introduction and instructions (10 minutes)

1. Explain that SRH service providers often must address issues that make people·-dient~

and providers alike-feel uncomfortable. such as sexual activitie~ or h0dy part .. that areconsidered private. Clients \vho do not know the "medical" tenns for \\ hat they are try ing todescribe may use slang words or common terms that might make "omc pro\ider:, feeluncomfortable or may avoid saying the words altogether. On the (l(hcr hand. pro\idcr" nu:use words that clients do not understand but are (00 embarrassed to a~k ahout. Thi" can constitute a major barrier to communication.

2, Explain that in this exercise the participants will try to identify all (1f the teml" that they canthink of for various sexual acts and body parts. including both "mL'clical" lor "~cien(ific"i

terms and slang or common terms. To communicate effectively. the provIder mu ... t kJlOh the\\'ords that a client \vill understand. However. the provider should not feel oblIged ll) liSt'

throughout the counseling session words that arc consiJcruj "olfcn~l\'C.... InqcaJ. theprovider can identify the word that a client uses for a particular body part (II' acti\iry andthen explain to the client that when a rarticular medical term i ... u...ed. It rder.; (n th~lt r;lrt \.'ractivity. (This may be a difficult distinction for providers to gra"p: the tramer \\ill rrohahlyneed to repeat this several times both during this session and after, )

.,. Training Tip

The purpose of this activity must be explained clearly (0 the rarticipants, ao;; some might feel as if the trainers arc just trying to get themto say "dirty" \I,'ords. Similarly. it is important to note that some participants may experience discomfort during this exercise If theyrespond emotionally to the words and feel offended. While SUPP(lrting their reaction. note that their discomfort could be an imp0rtantlearning opportunity. as it shows honestly how pn1vid':h and clienhmight feel about hearing or Llsing the"e words ...\ ... k tIll' r;,.(rticirant...

how they can learn from this to communicate beltcr with dcnL"

It is important to acknO\vledge issues that may anse when this exer

cise is conducted with a mixed-gender group. In some circum~tanccs.

the participants may not feel comfortable saying scxualterm.s in frontof members of the opposite sex. While one goal of this e:\erci~ is tohelp the participants get beyond this discomfort. it is imponant tostart this process in a sensitive and nonthreatening way. If nece>.sary.trainers should consider conducting the exercise in single-sex groupsor ensuring that the trainer is female when the participant~ are

predominantly female.

EngenderHealth ComprehenSive Counseling for Reproductive Hearth-Trainers' ~lanual 87

Session 16

3. Divide the participants into four groups. Post the prepared flipcharts on the wall.

» Training Tip

Instead of using broad categories for headi.ngs (e.g., "male sexualorgans," "sexual behaviors," etc.), more specific terms can be provided to the participants, with more flipch:ut sheets (e.g., "penis,""scrotum," "masturbation," "oral sex," etc.).

This activity also can be tailored to working with a specific population or subgroup (i.e., participants can braimtonn a list of words thatmight be used by different groups of people. such as adolescents,men, or older men and women, among other";;'.

4. Explain the steps for this exercise:

• Each group will start with one of the t1ipcharts and write down all of the words that thegroup members have hcard of (both medical and local) to describe the heading on thesheet they have been given.

• After a few minutes. the trainer will ask each group to move to the next flipchart. Afterreading what the first group wrote. they can write ar:.y additional medical or local slangterms that they have heard.

• The groups will continue to move when time is called. until every group has had a chanceto add words under all of the headings. A large-group discussion will follow.

~~~~~~-~-~-~-----.

a+ Training Tip

This activity can be structured in several different ways:

• In the version presented here, you need wall space to post all ofthe fljpcharts at the same time and room for the small groups tomove easily among the papers. The physical movement and timeallowed for informal reaction to the words is a good feature of thisapproach, as it allows for more "honest" responses.

• If wall space is not available, small groups can take turns writingtheir words and then pass their flipchart to the next group to writeadditional words-that is, the f1ipchart can move while the peoplestay in the same place.

• To save time. small groups can be assigned one or more headingsand the results can be shared in plenary, without passing theflipchart to other groups. However, you need to allow time withinthe discussion period for the participants to react to the words ofother groups.

• If you are very short on time, this exerci se can be conducted as alarge-group brainstorm, with the trainer or volunteers writingdown the words on the flipchart. However, this type of exercisetends to be dominated by a small number of more vocal, "braver"participants.


Session 16

Activity B: Small-group exercise (15 minutes)

1. Randomly assign each group to one of the tlipchans. distribute marker~. and ask them to

start. Allow about 5 minutes for the first round of writing.

2. Then ask the groups to move to the next tlipchart (give specific directions-<.g, move to

the flipchart on your left). The follow'ing "rounds"' should take le~s time, as there will be

fewer words to add for each round. However. the participant~ will need time to read what i"

already entered on the flipchart.

3. After the last round is completed. ask the participants to return to their sealS.


Ask for different volunteers to read each column of each flipchart. Then faeditate a Luge

group discussion by asldng.:

* What was it like for you to hear and say these word.;?

* Which category had more terms-medical language or local slang·? How do you exrlaln

that?

* \Vhich local slang terms do you think you could use to communicate m(lrc CllCdl\ely wtth

clients? How would you do that')

* How could you respond if a client uses a term tkll yuu cot1~ider crude ('I" 111~lppr\)f'n;lle)

* How can this exercise help us to communicate better with chent,;l

Part B: Using Simple Language

Activity 0: Introduction and instructions (15 minutes)

1. Explain that, besides needing to be able to bridge the gap between client and rro\lder \In

sexuality-related words. providers need to be ahle to explain sexual ~md rerroJuctl\e rhysi

ology and medical processes using simple. nonmedical terms. The purpose of thIS exerCbC

is to give everyone a chance to practice the skills l)f giving simple expbn:Hions.

2. Ask the participants to open their handbooK-: and tum to Ses,ion 16. Find the C\plan:ltlon..;

of sexual and reproducti\·e anatomy anJ phy~iology and knc the p:iJli ..... lr:ln" uke rurn,

reading each definition. l':ote that these are just gUidelines: everyone will have thclr own

way of saying things. but this is to show how simple the explanation can ~.

3. Divide the participants into groups of three. with as much space as pc':,slbk bet\\e~n the

groups. Within each group. ask for a volunteer to be the tlrst one to play the "pro\lder" and

another to be the "client." The third person will he an "obseryer." IThe roles will r..: shifted

for each of three role plays. so that by the end of this exercise each pJrtlcipant \\111 haw

played each role.)

4. Explain that you will list several words on a fl ipchart. and that the "pro\'idd' will have 5

minutes to explain those words to the "client:' Remmd the participant" that the "provider"

needs to ask what the "client" already knows and to use local slang, as necessary. and the

"client" can ask questions at any time.

EngenderHealth ComprehenSive Counseling lor Reproductive Health~Trainers t.1anual 89

Session 16

Activity E: Small-group work (15 minutes)1. Write the words ovulation, sexual intercourse, conception, and contraception on a flipchart

in the front of the room. Ask the "providers" to start the ["ole play.

Jt+ Training Tip

During the first role play, remember to move quickly from group togroup, both to observe and to make sure tra.[ the instructions havebeen understood correctly. If one group is not following the instructions, correct them gently but immediately. If more than one group isconfused, stop the role plays, explain the imtruetions again to all ofthe participants, and start over. If one participant in particular is having problems with the task, come back to that group after checkingwith the other groups, and provide additional guidance.

2. After 5 minutes, ask the "providers" to stop their explandiol1s, whether they are finished ornot. Ask the partici pants to switch roles.

3. Write the words menstruation, miscarriage (spontaneoll l,' abortion), and induced abortionon the tlipchart and ask the new "providers" to begin.

4. After 5 minutes, stop the "providers" and ask the participants to switch roles again.5. Write the words sexually transmitted infection, discharge. oral sex, and anal sex on thetlipchart and ask the new "providers" to begin. Stop them aftcr 5 minutes.

Activity F: Discussion (10 minutes)Facilitate a discussion based on the following questions:* What did you learn from this exercise?* Which terms were the most difficult to explain? Why?* Which tenns were the easiest to explain? Why?* Did the "providers" always check to see what the "c1ient~." knew already, before beginning

the explanation? What happened when they did not?* Did you have enough time? How could you explain these terms in less time?* How can you apply what you have learned in your work'.'

90 Comprehensive Counseling for Reproductive Health-Trainers' Manual EngenderHeaJth

Session 17Using Visual Aids to Explain

Reproductive Anatomy and Physiology

Objectives

• To develop their own simple visual aids to use to explain the reproductive "y"tem to client-.

• To explain the importance of being ahle to draw the reproduCli\e "ystem. even ii they neverdo this with clients

Materials

• Overhead projector and preprinted wmsparencies of the male .mJ female reproctuctl\e anatomyand physiology

• Plenty of writing paper and pencils

Advance Preparation

I. Copy the reproductive anatomy illustrations (Appendix ]) onto lran"parencie.".

2. Practice using the transparencies and explaining rcpruoucti\\: an.ltpmy ;'111,1 ph~ ~h;l,l~:. Ylll!

should be able to explain male anatomy and physiology in 15 minute" and female anatomyand physiology in 10 minutes. Refer to Session 16 in the PaI1icipant"s Handbt'ok (pa~e"

76 to 78) for simple descriptions of anatomy and physiology to incorporate into your presentation.

3. Review Session 17 in the PaI1icipant's Handbook (page 791 for complete ana10ll1: drawingsand the relevant section from the Introduction for the Trainers f page x.Yii l.

4..'dake sure that the transparencies are in the correct order hefnre"taning the S('""I\'[1

Time


Presentation/drawing , 30 min.

Discussion .

Discussion. . . . . . . . . . . . . . . . . . . . . . . . .. .. . .... 5 min.

. .... 5 min.

A. Pairs exercise .

B.

c.D.

EngenderHealth ComprehenSIVe Counseling for Reproductrve Health-Trainers· Manual 91

Session 17


Activity A: Pairs exercise (5 minutes)

1. Hand out a blank sheet of paper to each participant. !'vlake sure that all handbooks areclosed.

2. Divide the participants into pairs. Ask each pair to use one sheet of paper to draw the external and internal reproductive anatomy for the man and the other sheet for the external andinternal reproductive anatomy for the woman. Advise them to use pencils, if they have them.

Jt+ TrainingTip

This simple exercise touches on a number of important issues forprov:.ders. Keep the following considerations in mind to make themost of this opportunity.

• Expect a lot of nervous laughter when you ask the participants todraw the reproductive systems. This is normal, and good for thetraining, because it reflects how clients lTlay feel when they seevisual aids showing the reproductive system. However, this isalso a serious exercise, with important earning objectives. It isimportant for the trainers to model acceptance and understandingof the laughter, but also to help the participants focus on the taskand take it seriously.

• Be careful about "dirty jokes." It is l'Ci)' easy to offend othersand to seem disrespectful, particularly Vv hen teasing about thedrawings. If joking and laughing seem to make some participants angry or withdrawn, gently turn ilinto a learning experience by pointing out how normal the joking is but by also askinghow it might make clients feel.

• Most medically trained participants will quickly tell you thatthey learned anatomy and physiology in rheir training and probably do not need this session. However, this session is not somuch about what the participants knmv, hut about their ability toconvey what they know to others. This individual exercise is thusa gentle but humbling reminder for those participants that, whileone may know some things in his or her head, it does not servemuch purpose for the clients if he or she cannot explain thisinformation clearly and simply.

• Many participants will protest, "I am not an artistf" That is okay,as you are not asking them to be artists. In this session, they willlearn how to make better drawings themselves or how touse existing materials more effectively. However, by drawing thereproductive systems themselves, the participants reinforce themental learning process by using their hands and by creating

(continued)


•

.... Training Tip (continued)

their own visual representation. This will help them rememberthis information better and he more confident about explainmg itto others. whether they use a drawing or not.

Putting the participants in pairs is \'ery important. as it allow ...both participants [Q laugh together about how little they remember from their previous training and about how awful their drawings are. Some participants will know more than other;;, and theywill help each other to figure things out. Additionally. sayIng"this is our drawing" tak.es away the embillTa.ssment of .. aying"this is my drawing." Finally. working together on il gi\'es thempractice in talking with another person about the parts \)f lhebody and processes that the~ llsuall~ Ji ... cus:- unly in L'liI1lc,ilterms (if at all).

Session 17

Activity 8: Discussion (5 minutes)

1. Ask the participants to hold up their drawing ......0 that others can look af\.'und the r(lOm ~tnd

sec how everyone fared in the assignment.

2. Facilitate a discussion by asking:

* What did you learn from doing this e,'\crcise',>

* Why did people laugh when they were doing this l

* Did you learn about anatomy in your pre\'iotls training':' If ye:-. what W~b Jlfferent a~,)llt

this approach?

Activity C: Presentation/Drawing (30 minutes)

I. Explain that you will nm\! re\'iew basic rcproducti\'c anatomy and phy-.iology. U"ll1g "Imriedrawings on transparencies. The participants will now work on their own. kecrmt: theirhandbooks clo~ed. Give each participant [WO hbnk sh~~[:; ai pap~r anJ ~hk them t" ,".';'!what they see on lhe transparency. Again. explain lhat thi" is not meant to mak.e "arll't...·· I'lltof them. but to help them remember detJils of reproducti\'c anatomy and better nplainanatomy to clients. (5 minutes)

2. Present the transparency sheets in the correct sequence. Lay one tran ...parcncy down. givethe participants time to copy it. and then brie!ly explain what the part" arc and hnw thc~

work. Refer to the Participant's Handbook. (Session 16) for a simple explanatlOn ul eachorgan and how it \\lorks.

3. Repeat the process with the next transparency, By laying them on top of each other. youstart out simply and gradually build up to the complexity of the Internal "y,tems Youshould need 15 minutes for male anatomy and physiology and about 10 minute'- iar femaleanatomy and physiology,

EngenderHealth Comprehensive Counseling for Reproducllve f-ieal:h-T~a;ners' ~.1anual 93

Session 17

Jt+ Training Tip

In the trainer's set of transparencies, each one is a simple drawingshowing a different aspect of the reproductivl~ anatomy. (The maleanatomy includes the bladder and urethra. These are not technicallyparts of the reproductive system, but need to be explained becausethe urethra is involved in ejaculation.) By Llsing them in sequence,layin.g one on top of the others below, you '..:an explain in a simplified, step-by-step manner the complexity of the internal organs andhow they interconnect.

The participants have drawings of the complete systems in theirhandbooks. However, during the presentatioli, you will want them tofollow along with the transparencies and draw the different parts(with their handbooks closed). This helps them to remember betterand builds confidence in their ability to cxpLlin. Such an approachreplicates a technique that has been used many times in vasectomycounseling trainings and in counseling tralr ings of trainers and hasbeen found to be vel)' effective. Experience has shown that after theexercise, the participants would often use hrGlks or other free time towork on their own anatomy charts.

You will need to be able to go through the transparencies in 15 min- I

utes for the male anatomy and physiology and in 10 minutes for thefemale anatomy and physiology. (More time is aliowed for the malebecause it is a little more complicated to draw and because the participants tcnd to be less familiar with the nule reproductive systemsthan with the female reproductive systems.:, Practice ahead of timeto be sure you can do this, building in time Cor the participants to dotheir own drawings and for a few questions to be answered.

If an overhead projector is not available, the trainer can conduct thisexercise by drawing the anatomy on flipchalts. in the same sequencethat is used for the transparencies. Practice doing this so that you cando it quickly, but do not expect to be "perfect"; it is good for the participants to sec that this can be done without hcing an expert artist.


Facilitate a discussion based on the following questions.

* What did you learn in this session that you did not know before?

* How can you use what you have learned in your work':'


EngenderHealth

Part IV

Helping Clients AssessTheir Comprehensive SRH Needs

and Providing Appropriate Information

In these session". participants hegll1 applyIng ~lltitude' and

communication skills to carry out the c\)un.;eling t~hk-. th~H

comprise the four general nhjecti\"cs fpr thl' training I-klrin~

clients assess their own comprehensiw SRH need, require,

two-\\·ay communication hetwccn the ..'lien! and the pr,)\der.

The pro\"icler begins by asking appropnat·: quc~tion~: the client

responds and the pro\xlef listens: the PW\IJcr ~I\"e, l!l!l)I1T1thl:l

th:1t the client i" lacking {If corrects mi,inf"I1T1Jtion reLned tll

the dient's needs: and then the p(()\"idcf helps the client cunslder

how the information applies to him or her and his \)r he; le\d

of risk. This crucial phase of counseling th~b I' J Ll)mhinatll1TI

of the first two general objecti\'es-helping: client- ,1'~6,

their need for a range of SRH sC'niccs. inlormatlon. ~lnJ

emotional support. and pro\"iding informatic'n arrropflJte [(I

[heir problems and needs.

ComprehenSive Counseling for Reproduclive Hea'th-Trainers Manual 95

Session 18Introducing the Subject of Sexuality with Clients

Objectives

• To be able to explain to clients why they will be discussing scnsiti\'e and personal Issue" intheir counseling. such as STIs and sexual relationships and bel1a\'iors

• To list key points to cover with client, to help put them at ease in these discus"lon-

MaterialsNone needed

Advance PreparationReview Session 18 in the Participant's Handbook (page (:{)I.

Time

Demonstration role play. feedback. and summary. . ... 10 'Tl"n

Role plays/discussion, , , .


A. Inlroductionlbralnstorm _ , .

B. Discussion .... ,.,., ..

C.

D.

Time

15 rnr.

EngenderHealth Comprehensive Counseling for Reproductive Health-Traine's' r.lanual 97

PREVIOUS PAGE BLANK

Session 18


Activity A: Introduction/brainstorm (5 minutes)

1. Note that to introduce the discussion of sexuality issues ill a counseling session, the provider must overcome both his or her own nervousness and the client's possible embarrassment in response. Having a structured approach to beginning the discussion will bothincrease the provider's confidence and ensure that key j ssues of concern to clients areaddressed. The provider must remember, however, that it is his or her responsibility toinitiate these discussions and to put the client at ease.


* How can providers introduce the subjects of sexuality tHY and STls, sexual relationships, and sexual behaviors in a way that puts clients at UbG')

3. Encourage three to four responses. (Since you will be referring quickly to the Participant'sHandbook, do not write their answers on the flipchart.)


Refer the participants to Session 18 in their handbooks. Discu';s each key point to cover withclients. For the examples, ask:

* How would you say this to clients in your own service :;etting?

Activity C: Role plays/discussion (15 minutes)

1. Divide the participants into pairs. Explain that the particIpants will role-play being theprovider and introducing the subject of sexuality to a clictlt, following the guidelines in thehandbook. The participant in the client role will choose olle of the client profiles as his orher role. They will have only 2 minutes for each role play and then will switch roles, withthe new "client" choosing a new profile.

2. Before starting the first role play, check to see that each pair has identified who will be the"provider," who will be the "client" and which profile thc'client" is playing. (It is okay formore than one group to role-play the same client profile at the same time.) (5 minutes)

3. Ask the participants to start their role play_ Stop them after 2 minutes. Allow for I minutebetween role plays, to let the new "client" choose a different profile. Announce the time forthe new role plays to start. Stop them after 2 minutes. (5 minutes)

4. Briefly request feedback from the participants by asking: (5 minutes)

* How did it feel to play the role of the provider?

* How did it feel to play the role of the client? What did you observe about the"provider's" body language and mannerisms as he or she explained the need to askquestions about your sexual life?

Activity D: Demonstration role play, feedback, and summary (10 minutes)

1. From your observations during the practice role plays, select onc pair to demonstrate howto introduce the subject of sexuality to a client. (2 minutes)

98 Comprehensive Counseling for Reproductive Health~Trainers' Manual EngenderHeallh

Session 18

:2. Ask the rest of the participants to gi\'e feedback on the rok play h\ a"kin:,:'

* What \\as going on between the "provider" and the "c hent'·)

* What did the "provider" do that ",,'as effective in this situation')

* What might the ;'provider" consider doing differently next time')

3. Summarize the session by reviewing any of the Essential Ideas from the PartICipant'sHandbook that were not covered during the feedback, Emphasize that it is the pronder'sresponsibility to be comfortable enough to introduce the subject 01 scxualit! ;.lI1d to help theclient feel comfortable about responding to questions.

EngenderHeallh ComprehenSive Counseling for Reproductrve Hea lll1-Tra:ners' 1.1anua! 99

Session 19The Risk Continuum

Objectives

• To identify risk for pregnancy. transmission of HIV. and transmission of other SIb for \~triOl!'practices

• To explain how one beha"ior can be high-risk for one condition and low-ri~k for another• To identify \vays to lower the risk for some bcha\'iars• To explain in simple terms which beha\-iors put people at risk for pregnancy. HI\', and ()rher

5Th

Materials

• White letter-size paper• Three different colors of cards or paper• Scissors

• Pens and markers

• Tape

Advance PreparationI. Review Session 19 in the Particip3nt's Handbook (page 891 for background on the ri,,\.; ((In

tinuum and on factors that intluence risk,2. Review the Training Tip for .-\ctivity B, and decide how you want to distribute the ~ch~l\ior

cards.

3, Prepare four risk-le\-el cards. using white letter-size cuds or paper. \\irh the i01[()\\ll1~ ti\lL'~""No Risk:' "'Low Risk:' "\kJIU!11 Risk:' and "High Risk:'4. Prepare behavior cards using colored paper or cards: these cards should he ahllLlt ld i the

size of a sheet of letter-size paper. Each beha\'ior will be written on three card", with 011':card labeled "Pregnancy Risk:' the second one labeled "HIV Risk:' and the third Iah-cled"STI Risk:' Try to use one color of paper for all of the "Pregnancy Risk" card" t e_g_. l>luc I.a different color for all of the "HIV Risk" cards (e.g .. yellow J. and a third color for ~l!l ofthe "STI Risk" cards (e.g .. pmk). (See Trainers' Tool. page 107. for the beh<.l\lors and fordetails on preparation of the cards.)

5. Post the risk-level cards high on a wall. with plenty of space between each card and plenl:of space below them for participants to post the behavior cards. Place the ctrd, in the nrdershown below. to create a contmuum from no risk to high risk.

l3 Low RiskI _! Medium Risk [ High Risk

EngenderHealth Comprehensive Counseling for Reproductive Health-Trainers' ~.1anual 101-<:IJ10I.IS P,!\GE BLANK

Session 19

6. Make sure that the space in front of the wall is cleared so the participants have enough room

to move around as they post the behavior cards.

7. Prepare enough small pieces of tape in advance so the participants will be able to stick cards

or pieces of paper to the wall quickly.

Time



B. Large-group exercise 20 min.

C. Discussion............... . 30 min.

D. Summary............... . 5 min.

Note: This session is adapted from: EngenderHealth, 2002.


Session 19



I. Explain to the participants that. ha\'ing already focused on the attitudes and cl~mmum:atil")n

skills necessary for effective counseling. in this next section of the training the group willconsider the infonnation needed by clients and pro\idcrs. to help clients assc ...... their owncomprehensive SRH needs,

2, Explain that much of what happens in helping clienh to explore theIr own nCL'ds is abouthelping clients to accurately percei\'e their own risk-\\hcther for unll1tenJeJ pregnJn.:y.STIs. or pregnancy complications-so they can make decision, that will reduce their level ofrisk. The concepts of risk and risk reduction pose a challenge tl) provlJL'[,\ and cliL'nh alikeOne reason is confusion about the facts of HIV and STI tr,m'-mi"'sion and concertipn .-\nc)theris that the same behavior may be "risky" in one siluation and yet not risky in 311l'ther. or risk~

for pregnancy but not risk) for HIV and STb (and vice verS;1 I. This session tries to cLmiy the\'arious levels of risk from different behaviors and for dIfferent outcl)me,.

3. Conduct a quick brainstorm: Ask the participants to describe. In simple tenn" thc h-cha\'iorsthat put people at risk for pregnancy, for STh. and for HIV, (Hold no di,cussion at thi,point.) Explain that thc'Y will return to the,c concepts at the c:nd uf the ,e:-,iun.

Activity 8: large-group exercise (20 minutes)

I. :Ytake sure that the Participant's Handbooks are closed Distnhute all of the hcha\wr card"to the participants, trying to ensure that each partiClpaI1l has the same numhcr l'I':,lr,k

2. Explain that each card has a risk label (pregnancy. HI\'. or STI) alld a beha\iC'r. Thc pJ.rtiClpants must determine what level of risk that hehavior poses for pregnancy. HI\' tr~msmlS

sian. or STI transmission (whichever is written on the cardl. 'Norc' The "STI Risk" card,refer to risk for transmitting STIs olher {han HIVl For example. if a card say" "Prcgnanc~

Risk" and ":\1asturbation:' they must determine the !e\el of risk that masturbation poses forpregnancy. using the four risk-level categories ("~o Risk," "Low Ri ...k:· "\lcdillm Risk." nr"High Risk"),

3. Point out the risk-level cards placed on the wall. Once the participants ha\'c dctem11lled therisk level for a behavior and a condition. they should go to the wall and. u:>ing the tarc provided. place each of their cards on the wall. under the sIgn for thaI kvel of risk.

» Training Tip

Working individually or in pairs (teams)

This exercise can be conducted with individual participants placingthe cards. or in pairs or small teams, If the participants are alreadyknowledgeable on this subject. working individually is fine. However, if the participants do not know much in this area, there arcadvantages to putting two or more participants together. as they will

(conriTJucdl

EngenderHealth Comprehensive Counseling for Reproductive Health-Tramers' Manual 103

Session 19

» Training Tip (continued)

Working individually or in pairs (teams) (continued)have to justify to each other the placement of the cards, pooling theirknowledge, Greater learning happens when the participants discussthese issues among themselves prior to hearing "the answer" fromthe trainer. Additionally, individual participants will not feel soawkward about having misconceptions dbout this subject if theycan see that their colleagues are also confused.

Distribution ofcardsThe exercise's purpose is to clarify the participants' thinking aboutdifferent types of risky behavior and how 1:0 explain this clearly toclients. Two options give you a slightly different approach forachieving that purpose.

Oprion A: The basic issues of risks for pregnancy, HIV, and STIswould be reinforced most effectively by giving each participant (or"team") a set of three cards with the same hehavior and then havingthem decide the level of risk for that one behavior for pregnancy,HIV, or some other STI.

Option B: If the group is somewhat knowledgeable in these areas, itwould be more challenging to mix the cards and distribute them randomly.

When participants get "stuck"...For some of these cards, there is no "right" answer. The placement ofthe behavior in a risk category depends on many factors, such aswhether either partner is infected (for HIV and STl risk), whether it isthe fertile time of the woman's cycle (for pregnancy risk), or whetherthe spouse tells the truth about not having other relationships. So itis absolutely correct for the participants to say "it depends ..." whentrying to figure out where to place their card. The trainer shouldencourage the paJ1icipants to do their he~;t with the information (orlack thereof) that is given on the card. If that becomes too frustrating,the trainer can suggest that the participants write on the card to addthe information they need to place it in a particular category.Encouraging this kind of thinking is precisely the goal of thisexercise~to understand the basic factor~; of risk and the necessityof individualizing that infonnation to each client's unique situation.


Session 19


I. Once all cards are placed. read the cards in each category. begmning with ":'\0 Rt...k:· ,md a'l\..

* Do you have questions about the placement of any bchavior~ in this cate~0rY' Where dt'you think they should go and \vhy<'

2. Allow the participants to ans\ver each other's queqions whene\'er possihk and w ,haretheir knowledge of the relative risks of various beha\·iors. Affiml accurate re'rc1!1,e, ..mdcorrect any misconceptions that do not get resolved in discussion among the r~U1Kir;lnt'.

Place the cards in their correct categories if they have been incorrectly placed.

»+ Training Tip

The purpose of the discussion is to explore all of the c1itfcrent condItions that can change the risk level of a behavior. Emphasize that "Itdepends ..... IS the right answer most of the time. IThi s applies to thetable in the Participant's Handbook as well. ) When there i" Ji,a~rec

ment about the placement of a card. encourage the participant' hI

explain how they decided the risk lewl for those behavior carcb.

Sometimes the particip~Ults place behaviors that they find offen"ivein the "high risk" category. evcn if they present link ri"k for rre~

nancy or infection. If this happens in your group. recall hew. altitudes and judgments can intluence 3 provider's as..;cs-;mcnt ('f ri,k: Ina client's behavior.

Referring to the contimwm in the Participant's HandbookIf participants have very little knowledge in this area. ~Ulother 0rtwnfor discussion would be to refer them to the risk continuum [ahlein their Participant's Handbook. Then they could compare their 0\\ nplacements of behaviors with what is shown in the table. and di,clbthe differences. Howevcr. once you do this. you will lo~e some l'!their focus for discussion. since many participant-. will be morefOClI::;ed on reading than on listening: and thinkinf.

If at all possible. it \vould be best to help them thmk through the"eissues on their own. and refer them to the continuum at the end ofthe session. You may want to schedule time later lduring the \\J.rIl1up or wrap-up) for questions related to the continuuIl1.

3. After revie\ving the categories. ask the following questions about the whole contmuum(refer to the Participant's Handbook for possible responses):

* Why are some behaviors found in both "no risk" and "high ri"k" categoric,,'

* How does the relationship between two individuals affect their le\·el l)f ri"k for ..;('mebehaviors'J

* How can some behaviors be moved to a lower le\el of risk)

EngenderHealth Comprehensive Counseling for Reproductive Hea:th-Trall'e's· Vanual 105

Session 19


1. Ask the participants again:

* How would you explain to clients which behaviors put people at risk for pregnancy?

* How would you explain to clients which behaviors put people at risk for STItransmission?

* How would you explain to clients which behaviors put people at risk for HIVtransmission?

2. Tum to Session 19 in the Participant's Handbook and review with the group the risk summarystatements from the Essential Ideas. Point out the risk continuum table (if you have not doneso already); suggest that they review it on their own, and offer to answer further questionsrelated to the continuum at a later time in the training, as a follow-up to this exercise.


• Oral sex on a man• Oral sex on a \1, oman• Deep (tongue) kissing• Anal sex without using a condom

Session 19

Trainers'Tool

SRH Risk Continuum: Sample Behavior Cards

Behaviors• Abstinence• Masturbation• Vaginal sex using a condom• Anal sex using a condom• Sitting on a public toilet seat• Vnprotected vaginal sex with your spouse• Rubbing genitals together without penetration. une lathed• Unprotected vaginal sex with a monogamous. uninteeted partner• Vaginal sex with multiple partners. always using a cnnool11

Make three cards for each behavior--one for each area of risk. If pos.. ihk. make all of therisk cards the same color (e.g.. all of the pregnancy fISk cards would Ix: blue. all of the HI\'risk cards yellow. and all of the STI risk cards pink l.

Example:

PREGNANCY RISK

UNPROTECTED VAGINAL SEXWITH A MONOGAMOUS,UNINFECTED PARTNER

HIV RISK

UNPROTECTED VAGINAL SEXWITH A MONOGAMOUS,UNINFECTEO PARTNER

STI RISK

UNPROTECTED VAGINAL SEXWITH A MONOGAMOUS,UNINFECTED PARTNER

EngenderHealth Comprehensive Counseling for Reproductive Healli"l-Trainers' Manual 107

...o0)

()o3

-0ro:;:rCD::J(IJ

:<CD

oot;::J(IJ

~;;;l(0

§':IJCD

""D(30t;

~:<.(j)

I(j)0)

SI

--i(Us·CDVls:'";;;lce!.

Risk Continuum for Pregnancy, HIV, and Other STls--_._--_..._-,---- - -----_._.- -._- -_._-,-,-~-

No risk Low risk Medium risk High risk----.. "

Pregnancy • Abstinence • Vaginal sex using a condom • Unprotected vaginal sex with

• Masturbation • Rubbing genitals together your spouse

• Oral sex on a man without penetration, • Unprotected vaginal sex with

• Oral sex on a womanunclothed a monogamous, uninfected

• Vaginal sex with multiple partner• Deep (tongue) kissing partners, always using• Anal sex using a condom a condom

• Anal sex without using acondom

HIV • Abstinence • Vaginal sex using a condom • Anal sex using a condom • Anal sex without using a

• Masturbation • Deep (tongue) kissing • Oral sex on a man condom

• Sitting on a public • Rubbing genitals together • Oral sex on a woman • Unprotected vaginal sex with

toilet seat without penetration, your spouse

• Unprotected vaginal sex with unclothed

I a monogamous, uninfected • Vaginal sex with multipleI II partner partners, always using I

III

Ia condom II .......L ..... _.___

enCDVIVIo::J...I.

<0

Note: This continuum can change depending on social and individual faclors, such as involvement with other partners (for HIY and STI risk) or whether the womanis in her fertile time (for pregnancy risk), among others.

m;;;l(0(j)::J0(j)

I(j)

e:.s:

Other STls • Abstinence

• Masturbation

• Sitting on a public toilet seat

• Unprotected vaginal sex witha monogamous, uninfectedpartner

• Deep (tongue) kissing

• Vaginal sex with multiplepartners, always usinga condom

• Oral sex on a man

• Oral sex on a woman

• Vaginal sex using a condom

• Anal sex using a condom

• Anal sex without using acondom

• Unprotected vaginal sex withyour spouse

• Rubbing genitals togetherwithout penetration, unclothed

Session 20Exploring the Context of Clients'

Sexual Relationships

Objectives

• To explain why we need to ask questions about clients' se:'\ual relationshIp ..

• To list at least three ques[)ons that participants can use to help clicnt, t'.\pll're t!1tlf '-t'.\uallives, including social context and the circumstances under which they haH' ,cxual Intcrcourse

Materials

• Flipchart paper. marker''. and tape

Advance Preparation

I. Review Session 20 in the Participant's Handhook (page 9:il.

2. Revie\v REDI-Phase 2: Exploration. with a focus on steps for thts ..e .... ion ! rcpro.:luL'cd inthe Trainers' Tool. page 11-1.)

3. Prepare three tlipcharts with the headings for the areas to cxplore with client'- ('Sexual

Relationships:' "Communicating with Partner:' and "Parmer's Other Relation,hir'''l

Sexual Relationships

Questions from the framework:

• What sexual relationshlp(s)are you in?

• What is the nature of yourI relationship (includingI violence or abuse)?

I • How do you feel about it?

Questions you could ask yourclients:

Communicating with Partner

Question from the framework:

i • How do you communicatewith your partner aboutsexuality. family planning,and HIV and STls?


Partner's Other RelationShips

Question from the framework:

• What do ycu Kn,)\'~ a8CLJtyour partner·s sex.a.behaViors cutsloe yC~i

relationship?


4. For Activity R think of one sample question for each category that would be ca:'lcr for

providers to ask their clients. given the social and cultural norms of their community. (Seethe Trainers' Tool. page 113. for some ideas. These w1l1 differ from one culture and community to the next.)

EngenderHeallh Comprehensive Counseling for Reproductive Health-Traners Vanl;al 109

Session 20

Time


A. Instructions 10 min.

B. Small-group work . . . . . . . .. . 15 min.

C. Plenary/discussion .. . . . . .. . " 20 min.


Session 20


Activity A: Instructions (10 minutes)I, Ask the participants to tum to Session 8 in their handhooks and find Phase ~: E.xrloratipn in

the detailed description of RED!. Refer them to Step I. and the second hull\?!. "Explore thecontext of clients' sexual relationship<'

2, Ask:

* Why is it necessary to explore these areas of a client's personal life'?(Responses should be close to what is contained in the session"s Essential Ideas. on pag\? 9.,of the Participant's Handbook.)

3. Explain that the questions given in the REDI framework are a summary for pro\'ider,,: the,\?are lIol necessarily the questions that they wou ld actually usc in counse Iing, The questil~nsneed to be restated in simpler language ano in a way that would be acceptable to rro\'loer,and clients in their own communities. The purpose of this se"sion is to draft queqions thatthey would fcc! comfortable asking a client and that would elicit the information needed t(,help the client accurately assess his or her risk for SRH problems,

~. Remind the p,uticipants about Session IS rIntroducing thi..' Suhject of SC\lul it: \\l[!;Clients) . .\iote that in the counseling session. they would han:: already identifIed thc re~b(1nfor the client's visit and introduced the subject of sexuality. Also. for the rUrrthC nj thl'session. they should assume that they \vould already hav'c asked what the client I\.no\\,about his or her situation. coneems, and de ... irecl outcome from this visit (Explor~itl\)l1. StepI, tlrst bullet!. Now they are ready to 3..'1\. some nf the more sen"itjv·c que"tion, Jhout "e\U~l1behaviors and relationships.

Activity 8: Small-group work (15 minutes)I. Divide the participants into three groups. Distrihute the flipcharts with the hcaJing~ t)f the

areas to explore .

... Training Tip

If the groups are too large (i.e .. more than five participants pergroup), split the partiCIpants into six groups am.! assign two group" toeach heading. They can record their questions on notepaper. and thena trainer can write them on the flipchart during the plenary. It mayalso prove interesting to compare the questions from the two groups

2. Read the sample question that you dev'eloped for each t1ipchart headlOg. Ask for commentsand improvements-that is. how to make the qucstion marc acceptable to hath the pnwlderand client in their own clinic settings, Explain that you want them to draft que ... lions thatthey \vould feel comfortable asking a client and that would elicit the information needed fortheir assigned flipchart. Note that if they feel [hey could ask the questionl S) already wnlten

EngenderHealth Comprehensive Counseling for Reproducllve Health-Trainers Manual 111

Session 20

on the flipchart, this is finc, but that they should also add. morc questions, in case the clients

do not understand.

3. Explain that they will have about 10 minutes to draft their questions and write them on the

flipchart. Ask them to start.

4. Quickly visit each group to check that they understancl the assignment and see if they have

any questions.

Activity C: Plenary/discussion (20 minutes)

1. Have the first group (sexual relationships) post their nipchart and read the questions they

drafted. Ask for comments or addltions from the others. Add, as appropriate, from the

Trainers' Tool (opposite) for this activity. Have each gmup present their questions in this

way. (15 minutes)


* How do you think clients would feel about your asking these questions?

* What could you do to make the client more comfortable?

3. Note to the participants that, in a table for this session in their handbooks, they can fill in

some of the questions that the teams drafted for this exercise.

4. Also note that in Session 14 (Asking Open-Ended QUt~~tions), they drafted questions to ask

clients about their history, current health status, and concerns in specific areas of SRH.

Combined with the questions developed in this session, they now have sample questions for

aU of the bulleted items in Step 1 of Exploration.


Session 20

Trainers' Tool

Sample Questions to Explore the Contextof a Client's Sexual Relationships

Questions from the REDI framework

• What sexual relationships are you in?• What is the nature of your relationship

(including violence or abuse)?• How do you feel about it?

• How do you communicate with your partnerabout sexualitv. family planning, and HIVand 8Tls?

• What do you know about your partner'ssexual behavior outside of yourrelationship?

Questions you could ask your clients

[Confirm marital status. If not marr:ed. as,e]• Are you with somebody now?• How long have you been With thiS man o~

woman?

[If married]

• Is thiS your first mamage?

[For all chents:]

• What deciSions can you make Ii yOJr CLrrentrelationship?

• How many children do you have?• Are they all from the same father '"rS'the r?

• How does he or she treat you?

• How do you feel about tha!')

• How do you talk about faml!y alann'ng \\I:hyour partner?

• If you do not talk with him or her. why "'ct?• How do you talk about sex With ::ou r

partner?

• If you do not talk With him or her. '.'.'hy noP• How do you talk about HIV and 8TIs witn

your partner?

• If you do not talk With him or her..'Ihy net?

• How do couples deal With. outSiderelationships In your community?

• What do you know about your par.ner"s outside relationships (if any)?

• How do you feel about that?

• Does he have other wives? [depending onthe culture]

• What do you know about Signs of 8Tls?[If nothing. then briefly explain.]

• Have you ever noticed anything I:ke thesesIgns in your partner? What about you?

EngenderHealth Comprehensive Counseling for Reproductive Health-Trainers Manual 113

Session 20

Trainers'Tool

REDI-Phase 2: Exploration

1. Explore the client's needs, risks, sexual life, social context, and circumstances

• Assess what the client understands about his or her SRH condition or situation, what

worries or concerns he or she might have, and what he or she specifically hopes to

accomplish through this visit.

• Explore the context of the client's sexual relationships:

>- What sexual relationships is he or she in, what is the nature of the relationships

(including any violence or abuse), and how doe~: he or she feel about it?

>- How does he or she communicate with partners about sexuality, family planning,

and HIV and STIs'l

>- What does he or she know about his or her partm~rs' sexual behavior outside of the

relationship?

• Explore the client's pregnancy history and knowledge of and usc of family planning

methods, including condoms.

• Explore the client's HIV and STI history, present symptoms, and knowledge of part

ners' HIV and STI history.

• Explore other factor,; about the client's circumstances that may limit his or her power

or control over decision making, such as financial dependence on partners, tensions

within an extended family, and fear of violence, cliTlOng others.

2. Assess the client's knowledge and give information, as needed (will be covered in

Session 21)

3. Assist the client to perceive or determine his or her own pregnancy or HIV and

STI risk (will be covered in Session 22)


Session 21Information-Giving in Integrated SRH Counseling

Objective

• To identify basic information that clients need about SRH. regardless of the sen'ice thatthey request

Materials

• "New development"' cards

Advance PreparationI. Prepare "new development" cards for each client profile. to ensure that e3ch one h~IS J. sc..::

ondary SRH problem that needs to be addressed. These will be given alit 3t the begmning orthe session (see Training Tip. page 117. bottomJ.

2. Decide how the participants should be dIvided and profiles assigned (sec Training TIp. page116, bottom).

3. Revie\v REDI-Phasc Two: Exploration. Step :2 (see Trainer~'Tool. page 1191.4. Revic\v Session 21 in the Participant's Handbook (page 95t and hackground matenJls \,n

each SRH service area (Participant's Handbook. Appendixes :\ to DJ. Prepare a preSenLUh)non "Key Messages in Integrated SRH Counseling" (Activity B 1. based on the tark 111 theParticipant's Handhook.

5. Prepare and copy any materials specific to the health needs of the country or community mwhich the participants are \vorking. to use as additional handouts.

6 Locate the wallchart entitled: "Do you know your family planning choice<'" rJHl·ICCP.CSA[D. & \VHO. 1999). and obtain enough copies so YPu han:: at k~l~t one (('r (,J,-'hparticipant.

Time

Preparatory activity , 5 min.A. Introduction 5 min.B. Presentation 30 min.

I hour, plus 5 minutesof preparatory activity(preferably the daybefore this session)

Training Activities

C. Small-group work .

Time

.. 25 mIn.

EngenderHealth Comprehensive Counseling for Reproductive Health--Trainers' Manual 115

.---_.~._-----,... ,......' ... _'" ~,~,,-

Session 21


Preparatory activity (5 minutes)

The day before this session is to be conducted:

1. Explain that the next day's sessions will involve the "Client profiles" that were developed on

the first day. Specifically, the client's knowledge and need for additional information

in a variety of SRH areas will be assessed. Explain that they will have some time to prepare

as a group before demonstrating for the large group in a practice role play (Session 23).

------~---_.

» Training Tip

The agenda shows Session 21 as being part of Day 4 activities. If at all possi

ble, client profiles should be assigned and "new development" cards distributed

at the end of the preceding day (Day 3). In residential trainings, this would give

the participants the opportunity to work together during the evening. However,

if this is not possible, you may want to alert the pm-ticipants at the beginning of

the course to use any available time to review the basic background materials

on SRH. They will have 1 hour total to work together on Day 4, but that will

not be enough time to review the materials in allY depth.

2. Divide the participants into five groups and assign each group a client profile.

»+ Training Tip

This is the first of five sessions in which groups of participants will be assigned

to practice counseling tasks and skills using client profiles. There are three

options for how to organize this group work: keeping the same group of partici

pants working with the same client profile throughout the course (Option 1),

keeping the same group of participants, but changing the client profile (Option

2), or randomly assigning participants to profiles, changing with each day

(Option 3). The trainer should decide how to organize the group work now, to

avoid confusion later in the training.

Option 1: Same Participants, Same Client Profile

This is the easiest format logistically, because the counseling practice will be

broken down into sequential steps and each practice role play will continue

where the previous one left off. In this way, the participants benefit from getting

to know one client's situation very well. Also, although the participants get less

"exposure" to the different client situations and less opportunity to learn from

other participants, they will be able to observe all of the "clients" during prac

tice role plays during and at the end of the training and will be able to learn

from the other participants in other group work.(continued)


Session 21

... Training Tip (continued)

Option 2: Same Participants, Different ProfilesThe benefit of this approach is that participants become familiar with the diiferent client protlles and the issues that need to be addressed in counseling. Itcould be time-consuming to bring a new group of participants up~to-datc oneach "new" client each time they are assigned to a new profile. Howe\·cr. thctime and confusion can be minimized If the participants k.eep the same profilefor each day of the training. For example. they would be in one "cllent"" groupon Day 1, when they develop the protlles: they could then receivc a diffacntprofile for Day 4 (the sessions on rapport -building and explorallon I, anotherone for Day 5 (the sessions on deCIsion making and implementmg the deCIsion). and yet another-and pOSSibly t\\"lt--for the final cOUlbclm,:; prJ.cticc(Days 5 and 6).

Option 3: Different Participants. Different ProfilesAssigning participants to different groups and different client profiles ea(:'!1 dayallows for the maximum cxpo.-;ure to information and idea:-. Ho\\ ever. it \\ iIibe the most confusing logistically. This option would prohahly work he.;t whenparticipants have h~1cl some counselin~ !rail1in~ ~l11d arc cxrcriclh."C,J in ~lt ;C.l-..t

one area of SRH.

3. Distribute the "new development" cards and explain that the participants now need ttl Cl'n:-.ider this new ~ituation <b part of the ,:licI1l':- pillfik .

... Training Tip

~lany of the client protlles may ha\"t~ been developed to fncus on ('nc SRHneed. However. the participants need to be aware that each client can ha\e ~e\

eral SRH needs at the same time. For that reason. the trainer should con,idereach client profile and write a "new development'" card. This will de~crdx

either something that has h:1ppcnco to the client or new ll1fl)fl11;ltll)n that ;h,'client is sharing with the pro\ider rc\ealing <m additIonal SRH need that l11U,t

be addressed (see Introduction for TrJ.iner~. page .xxiii).

4. Ask the participants to use whatewr time i' available between now and the next da;. to

review Session 2 I and the SRH background information in their handbooks I Appcndixe-.; .-\to D). They should identify which points should be covered with their as.;igned '"client'" andwhich points should be covered \I,"ith e\'ery client. regardless of then SRH condition l)r

need. (This corresponds with Step 2 of the Exploration Phase of RED!. and with .-\s'e" andTell in GATHER.)

EngenderHeallh ComprehenSIVe Counseling tor Reproductive Heaith~Trainers' Manual 117

Session 21

3. l'Varning! In counseling. there is never enough timc to co\t'r ull of the Inf()rmJ.tll'n J.b~)UI

all areas of SRH that affect a client. The key task here is to ask questJon:- tl' ...ktcrnllIlcwhich areas to focus on in this counseling session and whi ... h pie((~., of ll1fl'rmationthe client needs the most. They will have only 10 minutes for their role rlays (In rappt.rtbuilding and exploration (Session 23). but even that is more than :-OI11C pw\idcr" havC' f(lrthe entire counseling session.

Trainers'Tool

REDI-Phase 2: Exploration

1. Explore the client's needs. risks. sexual life. social context. and circumstances I CO\

ered in Session 20)

2. Assess the client's knowledge and giYe information, as needed• Assess the client's knowledge of pregnancy-related carC' i if appropriatc I. rc,.;t,lQl.rtion

care (if appropriate). family planning. HIY. and 5Tb

• Correct misinformation and fill in gaps. as needed

3. Assist the client to perceh'e or determine his or her own preg.nanc~ or HI\" andSTI risk (will be conred in Session 22)

EngenderHealth Comprehensive Counseling for Reproductrve Heafth-Tralne~s' Manual 119

Session 22Risk Assessment

Improving Clients' Perception of Risk

Objectives

• To define risk assessment and explain why and how it is used in counseling

• To identify three reasons why it is difficult for people to perceive their own ri.;b

• To describe two ways in which they can help clients perceive and under-.t:md their pwnrisks for HIV and STI transmission and for unintended pregnancy

Materials

• Flipchart paper, markers. and tape

Advance Preparation

I. Review Session 22 in the Participant's Handhook (page 97) for prc<;cntati(ln ,;uldclinc,(Activity B), plus Step 3 of the Exploration phase of REDI. with J. focus on ,rep:- for rhi,session (see Trainers' Tool. page 1231

2. Prepare a flipchart with the definition of risk assessment and why we do It I ..... cU\ ity .-\ 1.

found in the Participant's Handbook (page 91h

3. Prepare a flipchart with the six reasons why clients underestimate rhelr risk (.-\ClI\lty B I.

found in the Participant's Handbook (pages 98 to 99).

Time45 minutes Training Activities

A. Introduction .

B. Presentation/discussion , ..

C. Discussion .

Time

.20 rr::l

Sore: This session is adapted from: EngenderHealch. 2002.

EngenderHealth ComprehenSive Counseling for Reproductive Health-Tra:ners' Manual 121

PREVIOUS PAGE BLAr~K

Session 22



1. Explain to the participants that, having discussed di ffcrent categories of risk and the behaviors and social factors that influence risk (Session 19'1, it is time to focus on the provider'srole in helping the client to assess his or her own risk.


* What does risk assessment mean to you?

3. After getting a couple of responses, post the tlipchart with the definition of risk assessmentand briefly explain it.

Activity B: Presentation/discussion (20 minutes)

1. Explain that most people generally underestimate their own risks in life, and that this includesrisks for transmission of HIV and STIs and for unintended pregnancy. Ask the participants togive a few reasons why people have difficulty in perceiving their risks for SRH problems.

2. Post the flipchart with the six reasons why clients underestimate their risk. Briefly explaineach reason.

3. Facilitate a brief discussion by asking the followll1g questions. (See the Participant'sHandbook for possible responses,)

* Why is a client's perception of his or her own risk so important?

* Considering the reasons why clients underestimate their risk, which reasons apply toour "profiled" clients? Why?


l. Ask the participants to refer to Session 8 (REDI-Phase 2: Exploration, Step 3), on page 34of their handbooks ("Assist the client to perceive or determine his or her own pregnancy orHIV and STI risk"). In the large group, ask them to brainstorm how they would actually askthe questions in the first two bullets.

2. Discuss each suggestion briefly to see if people agree with the questions, and then writethem on a flipchart.

3. Using one of the client profiles as an example, note that we should assume that the clienthas answered "no" to the first two questions, but that you know he or she is indeed at risk.Ask the participants:

* How would you explain the risks of HIV or STI transmission and unintended pregnancyto this client?

* What questions could you ask to help the client relate these risks to his or her own situation?

4. To summarize, ask the participants the following question. (Refer to the "DiscussionSummary" in the Participant's Handbook, pages 99 (0 100, for possible points to cover.)

* What are some of the ways in which providers can help clients perceive and understandtheir own risks?


Session 22

Trainers'Tool

REDI-Phase Two: Exploration

1. Explore the client's needs. risks, sexual life. social context and circumstances(covered in Session 20)

2. Assess the client's knowledge and gin information. a'i needed (cowred in Session 211

3. Assist the client to perceive or determine his or her own pregnancy or HIY and STIrisk

• Ask the client if he or she feels at risk for unintended pregnancy or for HIV and STItransmission. and explore why or why not

• Ask the client if he or she thinks that his or her p~u·tncrs may be at ri"k iDr unmtcnJdpregnancy or HIV and STI transmission. and nplore the reasons

• Explain HIV and STI transmission and pregnancy ri"b I as ncce,"ary l. rebtins them t(,the individual sexual practices of the client and hi.., or her partner"

• Help the client to recognize and ackno\\kd~ehh or her risk..; for HI\' al~d STI !~~m,mi,,

sion or unintended pregnancy

EngenderHealth Comprehensive Counseling for ReproductIve Health-Trainers' Manual 123

Session 23Counseling Practice I

Objectives

• To demonstrate the Rapport-building step of REDI (or the Greet step of GATHER I

• To demonstrate how to use open-ended questions to explore the client's needs. risk>;. sexuallife. social context. and circumstances IREDI-Phase 2: Exploration. Step I: or G.-\THER:Assess)

• To demonstrate how to assess the client's knowledge and to gl\'C information to fill gap". asneeded (REDI-Phase 2: Exploration. Step 2: or GATHER: A~"e"" and Tell)

• To demonstrate hO\v to help the client to percei\'c his or her own ri~k for HI\" and STI transmission or unintended pregnancy (REDI-Phase 2: Exploration. Step 3: (~r G.\THER:Assess and Tell)

Materials

• Pamphlets. educational flipcharts. sample family planning method". and ~U1y other "pwr<' fc~rthe role plays

• Flipchan paper, markers. and [apc

• Flipcharts with all of the client profiles. poqed where the partiCIpants can see them

Advance PreparationI. Revie\\i Session 23 in the Participant's Handbook (page !OI ),2. Review Sessions 8 (page 31) and 18 (page 85) from the Participant's Handhook. to prepare

for demonstrating the Rapport-building phase of REDL3. Develop a client profile to be used for demonstration role play~ throughout the re.;! of th~

workshop (the "sixth client" l.

4. Prepare a flipchart with the "sixth client" profile.5. Prepare a tlipchart with feedback guidelines for the role plays (see Traincr~' Tool. page 128 l,

6. Prepare the room for demonstration role plays. This might include setting up a tabk andchairs for a counseling space. and being sure that all pa.rticipants will be able to both sec andhear the demonstration. as well as arranging tlipcharts. clinic supplies. pamphlets. and other"props" that make the space look more like a counseling setting.

EngenderHealth Comprehensive Counseling for Reproduclive Health-Trainers' Manual 125

PP~VIOUS P,~GE BLAi~K

Session 23

Time

2 hours, 30 minutes Training Activities Time

A. Demonstration role play/feedback 30 min.


C. Practice role plays (10-min. role play, plus

5-min. discussion, performed five times) 1hour, 15 min.

D. Discussion............... . _ 10 min.


Session 23


Activity A: Demonstration role play/feedback (30 minutes)I. Post the flipchart entitled "Guidelines for Feedback after Role Play" and briefly dl"CU~'

2. Explain that the training team will first conduct a demonstration role play for the RapP1Htbuilding and Exploration phases of REDI lor for Greet. Assess. and Talk for GATHER I.Then. each "client"' group will do a role play for the same phases.

3. Post the flipehan and share the "sixth client" profile \vith the participants.4. Introduce the "client:' the "provider:' and any other players. (10 mil/lites. total J

5. Conduct the role play. As much as pos"itde in thi, role play. use the Cjuestipn, dc\clc1rcd bythe participants in the previous sessions. (10 mil/utes)

6. Ask the participants for feedback. following the posted guidelines. (10 mill1ITl' I I

Activity B: Small-group work (35 minutes)Ask the participants to return to their client groups and prepare hrietly 10 cClnduct J wk ph:with their client. They will demonstrate the rapport-building and exploration phJ'-•.> i,f RED!that they have developed in the preceding sessions. They \llll havr~ I0 minutc~ h)r the fl)kplay and 5 minutes for feedback.

Activity C: Practice role plays (1 hour, 15 minutes)1. Ask one group to \olunteer to go first. Briefly re\icw the llipchal1 of [he (lien! rn,tllc (I'·r

this group. Introduce the "provider" and thc "client." Start the role play.2. Stop the role play after to minutes. Spend 5 minutes discussing the ro!c play. f(1I!Ll\\ln~ the

first two bullets of the feedback guidelines.3. Repeat for the other four client groups.

»+ Training Tip

Following standard rules of feedback is importJnt for keepmg lhediscussions positivc and is helpful for all of the participant:' I "ecTrainers' TooL page 128). You may want to re\'iew these POlTIh.depending on how familiar the panicipants are with this tramIngmethodology.

Activity D: Discussion (10 minutes)1. Facilitate a brief discussion around the following question:* What marc do you [all participants I need to work on-knowledge. attitude,. or ,-kilb

to carry out these steps of counseling?2. ;'\fate the participants' responses on a separate tlipcharL this may pro\'Jde you with guidance

for funher work during the training or during follow-up.

EngenderHealth Comprehensive Counseling for Reproductive Heatth-Trainers 'l.anCJa! 127

Session 23

Trainers'Tool

Guidelines for Feedback after Role Plays

• [Ask the "cliem"] How did you feel during the role play? How were your needs met

(or not)?

• What did the "provider" do well? What improvements would you suggest?

• What communication skills did the "provider" use?

'------~-~~----~_._--_

._~_.~


EngenderHeallh

Part V

Assisting Clients in Making Their OwnVoluntary and Informed Decisions

At times. assisting clients in making voluntary and infomled

decisions may be a matter of confirming a deci..;ion that the

client made before he or she even entered the cliniC. In other

instances. this may im'olvc helping the client con,ider certain

issues and weigh several optiPlb to reach hi" or her deci ... ion.

While a provider's objective may he to help indi\idual.; nuke

their decision. often the deciSIOn-making proce;;s b he.l\ily

intlucnccJ by gcndl.'I" l.'\peLl~ltl\ lIh in ill.? c lll.'nt' ~ ~\.',: [.11 :-ctii n~

or by power imbalances in per ... onal rebtionshlps that may

limit the client's decision-making capacIty, Coun ...eling can

and should address all of thc'e fJeters.

Comprehensive Counseling tor Reproductrve Hearlh-Trainers' Manual 129

Session 24Gender Roles

Objectives

• To detine gender and gender roles

• To describe how gender roles can affect communication between SRH clienh and rr0\lder ...and bet\veen clients and their partners

• To describe how gender roles can have a negatiw impact on SRH

Materials


Advance Preparation

1. Review Session 2.+ in the Participant's Handbook I page 105l.

2, Prepare two f1ipcharts. one with the heading ",-\ct Like a \Ian" and the nth\.'[ lltkd ",-\.:[

Like a \Voman:' Draw a large box on each paper. with enough room to \\TllC me".lge .. rK-.[h

inside :md around the margins of the r0xe..;.

Time


A. Discussion., , .

B. Brainstorm , .. - . . . . . .. . .

C. Discussion .

D. Brainstorm _ .

E. Dlscussion .. _

F. Summary .

Time

. . 5 min.

.10 min.

Note: This session IS adapted from. EngendcrHcalth. ~()O().

EngenderHealth Comprehensive Counseling for Reproductive Heatth-Trainers' Manual 131

PREVIOUS PAGE BLAr~r<

Session 24



1. Ask the participants if they have ever been told to "act like a man" or "act like a woman."Ask them to share some experiences in which someone has said this or something similar tothem. Why did the individual say this? How did it make the participant feel?

» Training Tip

In some cultures, "act like a woman" does not have the same socialmeaning for women as "act like a man" does for men. If this is thecase in your setting, try using "act like a lady" for the heading.

2. Tell the participants that this session will look more closely at these two phrases. Doing sowill allow them to begin to see what messages we receive about being either male orfemale.

Activity B: Brainstorm (10 minutes)

1. Post the flipchart entitled "Act Like a Man." Ask the participants to share their ideas aboutwhat this means. These are society's expectations of I1mv men should act and what menshould feel and say. Write their comments inside the box.

._~~ .._.._-~~-~------,

» Training Tip

Another way of conducting this activity is to ask small groupsto prepare their own flipcharts and then share the results withthe others. If there are enough men to make their own group, it canbe very interesting to have them do their own versions of the maleand female gender-role boxes, to compare these with comparablegender-role boxes prepared by groups of female participants.

2. If necessary, ask the following questions, to include expeclations about sexual behaviors inthe box.

* What messages arc given to men about engaging in sexual activity?

* What messages are given to men about taking risks?

* What messages are given to men about what to do when they are in pain or need help?

* What messages are given to men about violence?

3. After completing the messages inside the box, ask the participants:

* How are men treated when they try to act "outside of the box"?

* What names are men called when they act "outside of the box"?

4. Write these names in the margin outside of the box.


Session 24


I. Explain that society uses these names to keep men II1slde thIs gender box.

2. Start a discussion by asking:

* How can "acting like a man" affect a man's relationship with his partner and chIldren:

* Ho\v can social norms and expectations to "act like a man" ha\e a negative impaC"l on aman's SRH?* HO\v do gender roles affect the interaction between a male client and a female provider~

Activity D: Brainstorm (10 minutes)

1. Post the flipchart entitled "Act Like a Woman:' Ask the participants to share their idea:about what this means. These are sociely's expectations of how women ,hould act and whatwomen should feel and say. Write their comments inside the box.

2. If necessary. ask the following questions. to include expectations about "exual b-chaviors inthe box.

* What messages are given to women about engaging in sexual acti\'lly 1

* What messages are given to \vomen about being assertive''>

* \Vhat messages are given to women about the importance nf beaut\··)

3. After completing the messages inside the bo.'\.. ask the particlp:mts:

* How arc women treated when they try to act "outside of the box")

* What names are women called when the\" act "outside of the box")

-1-. \Vrite these names in the margin olltside of the box.

Activity E: Discussion (10 minutes)

I. Explain that society uses these names to keep women inside this gender box

2. Start a discussion by asking:

* How can "acting like a woman" affect a \\Ol11an's relationship with her pJ.rtner andchildren')

* HO\v can social norms and expectations to "act like a \\oman" ha\'c a ne~ati\"e impact

on a woman's SRH?* How do gender roles affect the interaction between a female cliem and a male pn.1\lder'


Ask (he participants:

* What can SRH providers do to O\'ercome the negative impact of gender roles on men'sand women's SRH?

EngenderHealth Comprehensive Counseling for Reproductive Health-Trainers' \1anuai 133

Session 25The Effect of Power Imbalances

on SRH Decision Making

Objectives

• To identify four categories of behavior that people use to control their pJnner~ In differenttypes of sexual relationships

• To describe how such behaviors can affect the abilitv of partners to make and Larry (1utdecisions regarding SRH

• To explain the concept of social vulnerability to HIV and STh or unintended rretilJrK~

Materials


Advance Preparation1. Review Session 25 in the Participant's Handbook (page 107). Consider if or how )Pll \\In!

to lise the Particip;:Jnt'" Wnrksheet (case studie". with this 'e"sinn.2. Prepare a tlipchart showing the four types of behavior that people usc to wnt[ul their raIl

ners (Activity A).

3. Prepare four flipcharts. each with one of the four behaviors as a heading (.-\cti\·lt~ B f

4. Determine \vhat resources exist in the particip~u1ts' communities to which clients coulJ ~referred for gender-based violence. including physical. emotional. and ~e\Llal ~lhll~e. anJobtain contact information for these resources. Prepare a tl ipchart with the ('("Intact rnfomlJ.tion (Activity Cl.

Time


. __ 15 mn.Presentation/summary

Discussion _.. _ _..

Small-group work .. _ .

5 rT:fr..

. b rTvn

. .. 10 mm

A. Introduction .

B.

C.

O.

Note: This session is adapted from: EngenderHealth. 2002

EngenderHealth Comprehensive Counseling for ReprOductrve Health-Trainers Manual 135FPEVIOUS PAGE BLA[\:K

Session 25



1. Introduce the session by noting that for various reasons "power imbalances" may exist

between clients and providers. This will be discussed in more detail in Session 26.

2. This session focuses on power imbalances between partners. Explain to the participants that

making SRH decisions that require a partner's cooperation is sometimes not easy. It is even

more challenging, however, in a relationship where there is a power imbalance between

partners or where one partner abuses the other. This s~.:ssion first considers the impact of

gender and power on SRH decision making, then broadens the discussion to consider other

social factors that affect SRH decision making.

3. Normally, when we think of "power" or "power imbalances" in relationships, we think of

physical force. However, physical force is not the only type of controlling behavior that

people experience in their relationships. Ask the participants:

* What other kinds of behavior could be used to control a sexual partner?

» Training Tip

Participants or trainers may have experi ~ncccl these controlling

behaviors themselves. Thus, it is important to acknowIcdge this at

the beginning of the session, by saying that this activity might bring

up strong emotions for some participants and that they can speak

privately with a trainer to discuss what would make them more

comfortable.

4. After a few responses, post the prepared flipchart (see below) showing all four behavior

categories. Briefly describe each category, and give one example of each (see Participant's

Handbook, page 108).

Behaviors people use to control their partners

• Physical

• Emotional/psychological

• Financial

• Sexual

5. Explain that this session will explore how these behaviors can affect SRH decision making

and access to services.

6. In addition, note that, in most cultures, this kind of pmver is directed by men against women.

We will at first focus on such examples, but please be <Jiwme that this is not always the case.


Session 25Activity 8: Small-group work (10 minutes)1. Divide the participants into four groups. Assign 3 category of beh3\lOr-phy"ical. L'motional

or psychological, financiaL and sexual-to each group. and distribute the t1iIXhan~ accordingly. (The participants should have their handbooks closed for thi" Jcti\llY. I

~ Training Tip

Ten minutes is a very brief time for the group work. To ~ave tune.make the four groups by clustering people who are ~inmg next toeach other. If there are more than 16 participants. you can a,,~ignpeople to work in pairs-again. with the person siuing next tn }lIInor her-and have two or more pairs working on thL' "arne category.

2. Ask each group to brainswrm behaviors under their category that people use to controltheir partners. Have one member of the group list these behavior" on the tlirxhan.

3. After 10 minutes (total). ask the groups to stop.

ActiVity C: Discussion (15 minutes)1. Ask each group to post their flipchan and read the controlling beha\'lors from their list. (If

more than one group worked on the same category. have them take tum" reading from theirlists while a trainer writes the behaviors on the prepared tlipchart for that category.' OthChcan add to the lists after the group has reponed. and the tramer" Can add from the 11"t' III tn;.:Participant's Handbook (page 108).

~ Training Tip

You will see that many types of controlling hchavior-. will overlapcategories. For example. many examples of sexual aou"c are alsophysical abuse. This o\'erlap is understandable and relllf()rce" theway in which controlling bcha\'ior can affect ,,0 many a,pecl'o 0f aperson's life.

2. After all of the groups have reported. ask:* How do you think these behaviors would affect an individual's ability to make and carryout SRH decisions?

3. Note that many of these behaviors are included in the definition of "gender-based violence:'Although there is not enough time to cowr this issue in this workshop. panicipanb shouldbe aware of resources in their area for referral if a client "eerns to be at risk forphysical or emotional harm from his or her partner. Post the flipchan with the names andcontact information for whatever resources you were able [0 find in your preparation forthis session.

EngenderHealth ComprehenSIVe Counseling tor Reproductive Hearth-Trainers' Manual 137

_____• ... '.,I111 .......,I.'rl',;-.;;,';;

Session 25

Activity 0: Presentation/summary (15 minutes)

1. Give a short presentation, based on "Social Vulnerabi IitlCS and HIV and STI Risk" in the

Participant's Handbook (pages 109 to 110).

J» Training Tip

If time permits, first ask the participants what they think about each

topic (e.g., "Why are women more vulnerable to HIV/STI infection?"

"Why are youth more vulnerable ... '~" or "What government policies

contribute to people's vulnerability?").

2. If time allows, ask the participants how these same factors apply to other areas of SRH,

such as pregnancy prevention and safe motherhood. (Ex.cept for the biological factors, the

same social forces apply to pregnancy prevention and safe motherhood, with women and

youth limited in their access to information, financi3l resources, and health care services

and in their decision-making power.)

.,. Training Tip

The Participant's Handbook also includes a Participant Worksheet

consisting of case studies on power imbalances in SRH decision

making (pages 11 t to 116). These will help the participants more

fully understand and apply these concepts. They can be used as an

additional session, either as case studie~ or as role plays, or as

"homework" to be completed after the session. Note that the

"answers" to the case~study questions arc provided.


Session 26Helping Clients Make Decisions

Counseling Practice II

Objectives

• To identify the steps in the decision-making phase of integrated SRH coun"eling (REDJ~Phase 3. Decision making: GATHER: Help)

• To list at least one open-ended question to ask clienl;; for each of the four ;,;rep"• To describe the role of the provider in helping the client to make his or her own mformed

decisions and in supporting the client's sexual and reproductive rights• To demonstrate helping a client to make his or her own decision

Materials

• "Props" to be used during the demonstration role plJ.y• Flipchart paper. markers. and tape

• Prepared flipchart with guidelines for feedback (from Scs~ion 23)

Advance Preparation1. Revie\v Session 26 in the Participant's Handbook (page 1171.2. Prepare a flipchart with the four steps of the Decision-making segment of REDl1 page 14 I I

3. Prepare five tlipcharts. each with one of the steps of decision making a, a heJJIf1~ Thethird step will be divided for [\>,;0 groups. as shown here:

1. Identify what decisionsthe client needs

to make in this session

2. Identify the client's optionsfor each decision

3(a). Weigh the benefits,disadvantages, and

consequences of each option

• Options meet clients'individual needs

• Provide moreinformation asnecessary

3{b). Weigh the benefits,disadvantages, and

consequences of each option

• Who else would beaffected?

• Others' reactions

4. Assist the crient to makehis or her own realistic

decisions

EngenderHealth ComprehenSive Counseling for Reproductive Hea't~Trainers Manval 139

______I~-_, .....>u·_'"""" •

Session 26

Time

1 hour, 30 minutes Training Activities Time



C. Plenary discussion . . . . . . .. . 20 min.

D. Demonstration role play/feedback 20 min.

E. Practice role plays 15 min.

F. Discussion 10 min.


Session 26


Activity A: Introduction (10 minutes)1. Divide the participants into five groups. If they need to change seat''. ask them tl' ta.ke their

handbooks and their pens or pencils \vith them.

~ Training Tip

These are the fiw "client profile" groups for the nc.\t two coun~elingpractice sessions. Depending on which option you chose in Se ..sion21. these will be the same groups as the pre\ious day or different.

In Activity E, you will assign them a client profile for their prJc[icerole plays. Again. this needs to be con~i:-.ten[ with the optiullyou chose in Session 21 (i.e .. either the same a-" the day ix'fore ordifferent}.

2. Ensure that the panicipants keep their handboob closed during the follo\\ ing activity.Explain that helping clients make their own decisions is one of the maS! difficult steps incounseling, despite years of GATHER training (which includes a "Help" step i .-\",J..: the pJ.rticipants why this might be true. Facilitate a brief disclI';sion. making sure [hat [he points inthe Participant's Handbook discussion Sllmmaf) (pagL' 11:-; ) are (()\cred.

3. Post the prepared tlipchart (shown below) with the steps for the decision-making pha_,c l1fREDL and briefly review it.

Decision Making: Steps in Counseling

1. Identity what decisions the client needs tomake in this session

2. Identify the c1ienfs options for each deCISion

3. Weigh the benefits. disadvantages. andconsequences of each option

4. Assist the client to make his or her ownrealistic decisions

ActiVity B: Small·group work (15 minutes)1. Ask the participants to [urn [0 Session 8 in [heir handbooks and find the detailed de~cription

of the decision-making phase of RED!.2. Assign one step [0 each group (with the third step split bem:een two groupsl. Di ... tribute the

prepared flipcharts and the markers. Ask the participants to brainstorm que~tlons to askclients for their step and to list them on the tlipchart.

EngenderHealth Comprehensive Counseling for Reproductive Heatth-Tramers' Manual 141

_.~~-..~

.... ...._P,,~ ,

Session 26

3. Remind them to use open-ended questions as much as possible. Ask them to discuss in their

group how to explain key points to the client and to make notes for reporting in the plenary

discussion (but not on the t1ipchart).

Activity C: Plenary discussion (20 minutes)

Ask one member of each group to post their flipchart and read their questions. They should

also share their notes about how to explain key points to the client. Trainers and the other par

ticipants can add to the questions or make comments (4 minutes per group)

Activity D: Demonstration role playlfeedback (15 minutes)

1. Have several members of the training team conduct a demonstration role play for the

decision-making phase of counseling, using the "sixth client" profile from Session 23 (page

125). As much as possible, use the questions developed by the participants for each step.

(10 minutes)

2. Ask the participants for feedback on how well the role play demonstrated the steps of

decision making and on what improvements they would suggest. (5 minutes)

3. Remind the participants that power imbalances may exist due to differences in the status of

clients and providers. It is difficult to demonstrate the impact of status in a role play.

However, consider: (5 minutes)

* What impact could a power imbalance have on this interaction?

* What could the provider do to overcome the barriers caused by this imbalance?

Activity E: Practice role plays (15 minutes)

I. Have the groups move as far away from each other as possible, to cut down on distractions

during the role plays (which will be conducted simultaneously).

2. Assign one of the client profiles to each group (see Training Tip, Activity A). Have the group

decide who will be the "provider." (It should be someone who has not already

practiced counseling.)

3. Explain that each group will do a lO-minute role play of the decision~making phase of

counseling with this client. Ask the groups to remember what happened with this "client"

during the rappon-building and exploration role plays (Session 23, page 125) and to

imagine that they are continuing the counseling from that point. Explain that because the

role plays will be conducted simultaneously, discussion \vill take place in the large group

following the role plays.

4. Ask the "providers" to begin. Have the training team monitor as many of the groups as

possible, moving around as necessary. Stop the role plays after 10 minutes.

Activity F: Discussion (10 minutes)

1. Post the flipchart on feedback guidelines from Session 23 (page 128).

2. Facilitate a discussion on all three bullets.

142 Comprehensive Counseling tor Reproductive Health-Trainers' Manual EngenderHealth

Session 26

Trainers'Tool

REDI-Phase 3: Decision making

1. IdentiC),' what decisions the client needs to make in this session

• Help the client to prioritize the decisions. to detennine which are the moq importantta address today

• Explain the importance of the client's making his or her own decision:-

2. Identify the client's options for each decision

• ~any providers and clients feel that in most areas of SRH. client"-' dccbion-maklng:

optians are limited. An impol1ant role of the provider i" to layout the \~mou" dechlon"that a client could make. to explore the consequences of each. ThIS crnptlwer:- the clIentto make his or her own choice. which is a key c1emcnt of supporting thc .:Iicm·" "c\Lu!and reproductive rights.

3. 'Veigh the benefits, disad\'antages. and consequences of each option

• \1J.ke sure thJt the discussion center., on options that meet client< ir.Jj'.iJ·.lJl ned,.taking into account their prderenccs and concerns

• Provide more detailed information. a ... necessary. on the opti0n.; lh~ll the client I'

considering

• Comider who else \\'ouIJ be affcck~l hv cal'h dcci:-iol1

• Explore with the clients how he or she thinks that partners or family mcm~r.; 111;1\

react to the course of action (i.e .. suggesting condom use or discussing "e\.u.tlity wahpartners)

4. Assist the client to make his or her own realistic decisions

• Ask the client what is his or her decision (i.e .. what oplion he or she chl)(1"e,)

• Have the client explain in his Llr her Ll\\n words why h.:: or she i" nMkin~ thi:- ,k~'l"ll)n

• Check to see that this decision is lhe choice of the client. free of prc:-.'urc In,mspouse. partner. family members. friends. or service providers

• Help the client assess whether his or her decision can actually be carric-d out. fiwnhis or her relationship.... family life. and economic situation. among olh('[ i,,:-ucs

EngenderHeallh Comprehensive Counselmg for Reproducllve Heaith--Trainers' Manual 143

EngenderHealth

Part VI

Helping Clients Develop the Skillsto Carry Out Their Decisions

Making a decision about an SRH problem or need i:-; onl~ the

first step to\vurd the client .... meeting hi ... or her need. The

client then must lean? the clinic and earn nut thi;; deci"ICln lll1

his or her own. Some dccision~ (fpr example. condl>ll1 lhel

will require consistent action on the p:-lr, llf the client and

partners. Other decision'- I for C\ampk. to clln\"in('C' :l r:ir1ncr

to be tested for STh or HIV) require the clIent to mtluence

someone e1sc':-; bdla\"illr. TIlL'~e ~e~~!l111'" L"\;If11lne \'.,1\'"

in which the provider can help prepare a client tl1 C:lrry l>Ut

his or her decision. including helping rhe client develop

communication strategies and ~kilk

Comprehensive Counseling for Reproductive Heallh-Tra,ners Man~al 145

PREVIOUS P,;GE BLAI~K

Session 27Helping Clients Develop an Implementation Plan

Counseling Practice III

Objectives

• To identify practical ways for helping clients make a plan to carry out their SRH deci"i('1n

• To list the skills that clients might need to dC\'e]op to carry out their plan

Materials

• Flipchart paper, markers, and tape

• Prepared f1ipchan \vith guidelines for feedback. from Session 23

Advance Preparation

I. Review Session 27 in the Participant's Handbook (page 121) and REDI-Pha ... c -+Implementing the Decision (see Trainers' Tool. page 1501. (The handbook include" a "'<1.111

pIe plan" for a client who wants dual protection. rt is not used in this se ...... ic)Jl. hut it C.tIl he ~l

resource for the panicipanh or trainers. I

2. Prepare a flipchaJ1 showing the four steps of implementation (REDI-Phase -+. page I-lS I

Time


A. DiscussIon .

B. Demonstration role play/feedback .

C. Practice role plays .

D. Discussion .

Time

. . 15 'T'I,,'1.

10 ~'n.

. . 5 'Tl''l

EngenderHeallh Comprehensive Counseling for Reproducltlle Health--Trame.s Manual 147

. L\/IQUS PAGE BLANK

Session 27



1. Introduce the activity by telling the participants that it is important for the client, havingmade a decision, to have a specific plan for how he or;;he will carry out this decision and todevelop the skills needed for communication and behavior change.

2. Ask the participants to turn to Session 8 in their handbooks and find REDI-Phase 4:Implementing the Decision.

3. Post the prepared flipchart on implementation and briefly review the four steps.

Implementing the Decision:Counseling Steps

1. Make a concrete, specific plan for carryingout the decision

2. Identify skills that the client will need to carryout the decision

3. Practice skills, as needed, with t1IE~ providers'help


4. Note that in this session, the participants will practice developing an implementation plan tohelp clients carry out their decision (Step 1). (The nex.t session will focus On developingskills for partner communication and negotiation, Steps 2 and 3.)

5. Focus on Step 1 in the Participant's Handbook (Session 8, page 35). Ask for a volunteer toread the first bullet out loud. Note that sample questions are already given for condom use.Ask the participants what other questions they would ask for different decisions (usingclient profiles as examples). Note how open-ended qUGstions are used.

6. Repeat this process for the rest of the bullets.

Activity B: Demonstration role play/feedback (10 minutes)

1. Using several members of the training team, conduct a demonstration role play for helpingthe client to make an implementation plan, using the "sixth client" profile. As much aspossible, use the questions from the bullets.

2. Ask the participants for feedback on how well the role play demonstrated Step 1 ofImplementing the Decision,

Activity C: Practice role plays (15 minutes)

1. Divide the participants into the same five groups as in Session 26, with the same client profiles. Have each group decide who will play the "provider" (it should be someone who hasnot already practiced counseling) and who will play the "client."


Session 27

2. Explain that they \\:ill do a IO-minute role play of helping the "c1ient" tll makt.: a plan f\)rcarrying out the decision that was made in the last role play. continuing where they left offDiscussion will be conducted in the large group after the role plays.

3. Ask the "providers" to begin. Have the training team monitor a<; many of the groups as possible, moving around as necessary. Stop the role plays after 10 minutes.


Post the feedback guidelines flipchart (from Session 23. page 128) and facilitate a di"'(llSsionon all three bullets.


Session 27----_._--.._---- .~------~---------,

Trainers'Tool

REDI-Phase 4: Implementing the Decision

1. Make a concrete, specific plan for carrying out the decision

• Be specific. If a client says that he or she is going to do something, find out when,under what circumstances, and what his or her next steps will be in each situation.Asking a client "What will you do next'?" is important in developing a plan to reducerisk. For example, if a client says that he will Slart to use condoms, the providershould ask: "How often'?" "Where will you get the condoms'?" "How will you pay forthem?" "How will you tell your partner that you I,l,'ant to use them?" and "Where willyou keep them so you will have them with you when you need them?"

• Ask about possible consequences of the plan: "JImv will your partners react?" "Doyou fear any negative consequences?" "How will the plan affect relationships withyour partners?" "Can you communicate directlv about the plan with your partners?"and "Will indirect communication be more effectlve at first?"

• Ask about social supports. Who in the client's life can help the client carry out theplan? Who might create obstacles? How will the client deal with a lack of support orwith individuals who interfere with the client's efforts to reduce risk?

• Make a "Plan BO'-that is, if the plan does not work, then what can the client do?

2. Identify skills that the client will need to carry out the decision

• Partner communication and negotiation skills

• Condom-use skills

• Skills in using other family planning methods

3. Practice skills, as needed, with the provider's help

• Partner communication and negotiation skills

> Discuss the client's fears or concerns about communicating and negotiating withpartners about condom use, family planning, malernal health concerns, safer sex,or sexuality, and offer ideas for improving communication and negotiation

> For a client who feels that it may be difficult to negotiate condom use for HIV andSTI prevention, discuss whether it might be easier to introduce condoms for pregnancy prevention

> Role-play with the client possible communication and negotiation situations

• Condom-use skills

> Demonstrate correct condom use on a penis model, describe the steps, and ask theclient to repeat the demonstration to be sure that he or she understands

> Discuss strategies for making condom use morc acceptable to partners

> Provide samples of condoms (if possible) and make sure that the client knowswhere and how to obtain more

(continued)

150 Comprehensive Counseling lor Reproductive Heallh-Trainers' Manua! EngenderHealth

Session 27

Trainers'TooI

REDI-Phase 4: Implementing the Decision (continued)

• Skills in using other family planning methods

~ Make sure that the client understands how to use other family planning methodsthat he or she has selected by asking the client to repeat hack hasic inf(mnationand by encouraging him or her to ask for clarification


• Invite the client to return for a follow-up \"isit to provide ongoing "Uppl'rt \\llh deCI

sion making, negotiation, and behavior change

• Explain timing for medical follo\'."-up VIsit or contraceptive resupply

• Make referral for services not prO\'ided at your facJlity

EngenderHealth ComprehenSive Counseling for Reproductive Health-Trainers' '3anuai 151

Session 28Helping Clients Develop Skills

in Partner Communication and Negotiation

Objectives

• To identify possible reasons that clients may have for not talking with their ranner, 3f.0ut SRHconcerns

• To recognize deeper personal and social issues behind clients' difficulties in dixu"..;.tnf SRHissues with panners

• To help clients discuss SRH issues more effectively with panners. e\en in rdallonship, markedby violence or a power imbalance between partners

Materials


• Prepared flipchart with guidelines for feedback. from Session 23 (page J:8 I

• Prepared flipchart with contact information for local resources for pepple in yic.]cnl orabusive relationships (from Session 25. page un

Advance Preparation

L Review Session 28 in the Participant's Handbook (page 125l.

2. Prepare a two-column flipchart for Activity A (see page 15-+1. Be sure to make the left-hanJcolumn wider than the right-hand column. (See the Participant's Handbook.. page 126. foran idea of what the flipchart might look like when it is filled OULI

Time


A. Brainstorm/discussion ..

B. Brainstorm .

C. Demonstration role play . . . . .. . .

Time

. .... 15 mIn.

. ... 10 min

.15 min.

D. Practice role plays , 5 min.

E. Discussion . . 5 min.

Nore. This session is adapted from: EngenderHcalth. 2002.

EngenderHeallh Comprehensive Counseling tor Reproducl!ve Health--Trainers> Manual 153

PREVIOUS PAGE BI !-

Session 28


Activity A: Brainstorm/discussion (15 minutes)

1. Introduce this session by noting that even after attending a workshop like this, providersand trainers alike still may have trouble in talking with their own partners about sexualityissues and SRH concerns. Yet talking with their partners is a key component of mostclients' implementation plans. So, in this session, partici pants will discuss the difficultiesthat clients may have in talking openly with their partners about sexuality and the ways inwhich providers can help them develop communication skills and strategies.

2. Ask the participants to brainstorm responses to the following question: (Participants shouldhave their handbooks closed during this activity.)

* What are some reasons why clients may not talk ,vith their partners about 5RHconcerns?

3. Record the responses in the teft~hand column of the prepared f1ipchart (see the table "Barriersto Talking ... ," on page 126 of the Participant's Handbook, for ideas for this activity, ifnecessary).

,------_._----~~-----------_._------,

Barriers to Talking with Partners aboutSRH Concerns

Clients' Reasons Deeper PErsonal andSocial ~Cactors

4. For each reason listed, ask the participants to discuss the deeper personal issues (e.g., fears)and social factors that are behind it. After agreeing on c;lC:h one, write the response in theright-hand column, next to the reason.

5. If fear of violence or abuse does not come up in the brainstorming, note that under the bestof circumstances women may find it challenging to discuss sexuality issues with a partner.Ask how this is further complicated when there lS a power imbalance or violence or abusein the relationship (see Discussion Summary, page 127 in the Participant's Handbook, [ordiscussion points). Refer to the posted flipchart on local resources for people in abusive orviolent relationships.


1. Ask the participants to brainstorm answers to the following questions:

* What are some possible suggestions that you, as providers, can make to your clients fordiscussing sexuality issues and SRH concerns with their partners?


Session 28

* \Vhat are your options when a client absolutely rdu:-es to dL'>CUSS SRH concern" \~ lth hi"or her partner?

2. Record their suggestions on a separate flipchart. supplementing as nece:-sary from theParticipant's Handbook. Acknowledge that some suggestions may he ahout reducing theclient's risk for harm. (In other words. these would be realistic options. or "sur,ival strategies," for clients who are in potentially violent situations.)

Activity C: Demonstration role play (15 minutes)

1. Using members of the training team. demonstrate helping the client dewlap partner communication and negotiation skrlls. using the "sixth client" profile and working from theimplementation plan that was developed in the last demonstration role play. Try to the :-L)!l1C

of the suggestions listed on the tlipchart. including conducting a role play '\irh [he eiil'm. tl)help the client practice communicating with his or her partner (:"cc the P~lrtlciran(,

Handbook. page 126). (10 mimifes I

2. After the role play. ask for feedback or questions from the participants, (5 minures J

Activity D: Practice role plays (15 minutes)

1. Divide the participant:-; into pail":", Spread out the pair" aero:-s the rL1UIn .1:- much .::" l',)""ibk.to minimize distractions from the other role plays. Within each pair. decide who \\ ill rla~

the "provider," (Since there is time for only one role play. it should he :,omeone \\hn ha" Ol'tyet had a chance to practice counseling.) The "client" can choose whiche\'t?f cliem profilehe or she wishes.

2. Explain that the participants are to do a lO-minute role play about helping the ",;lIcnt"develop partner communication and negotiation skills. working from the impkmcntatiL)nplan that was developed for that client in the earlier session. There will be di~Clb,ion lT1 thelarge group after the role plays.

3. Ask the "providers" to begin. Have the training team monitor as many of the pairs a-" ['<h"ihk.moving around as necessary. Stop the role plays after I0 minutes.

Activity E: Discussion (5 minutes)

Post the feedback guidelines f1ipchart and facilitate a discussion on all three bulleb.

EngenderHealth ComprehenSIve Counseling lor Reproductive Health-Trainers' Manual 155

EngenderHeallh

Part VII

Final Steps in ImplementingIntegrated SRH Counseling

The final sessions in this curriculum help the p:.u1lClpants to

actually practice or apply lnt~grated SRH cClun~cling by

putting all of the components together. The participmls arc

now giyen the opportunity to practice J. completc cl1unscling.

session in counseling rok plays or in J. clinic::-il pra.:ticum.

using skills and approachc.; cP\ered in prc\iou" .;c,~il1n" an,1

receiving feedback.

It is important for trainers and pro\'lckr, tel rccogOlle that

applying new counseling skill.., aC4uircJ in training rc,!llirc~

more than training Itself: .-\dministratnrs and ,;ul~cf\isN';

need to he supportlYe of ncw practicc~ allel J.pprexh:hc.;. W

help participants and their co-worker.; adJlht te, ;illd "ustam

any changes that are requm:d. Also. pro\'ider" nc.:-J [,111,.\\

up from trainers and supcnisors to help them o\crc"mc

problems. continue to impro\e their ..,kilk J.nJ l11J.intain

their commitment to pro\'idlllg integrated SRH c,111n,clin~

ComprehenSive Counseling for Reproductive Hea::h--T'a:->ers I.larua! 157

f-'REVtous PAGE PI ,~. ",

Session 29Counseling Practice-Final

Objective

• To demonstrate integrated SRH counseling skills in role plays lor in a practlcuIll I. a"e",mfthe client's needs and risks. addressing content issu~s and counsellJ1g concern", ~1J1J ~lrrj~ l!1~

the principles and approaches discussed in this training

Materials

• Props for role plays I i.e .. ViSLl<L1 aids and materials thai \\ould nUrIlhtlly be ltlllllcilil .1 he.lithcare or counseling setting)

• Client proftle tlipcharb (from Session 6)

Advance Preparation

1. Organize transportation and other logistics for a clinical practicum. if possihk.

2. Revie\\' Session 29 in the Participant's Handbook (p3gC 1311 for specIfic qucstinn, tt) ]"kfor more in-depth role~play feedhack hy ohservers .

.3. Review the Detailed Steps for Session 29 and determine which option l(\ the fl)r the rl'kplay assignments in the final counseling practice session.

4. Prepare a tlipchart with the eiglH headings in hold from the "Ohservation and FeeJh.i..::kGuide for Counseling Practice" on pages 131 and 132 of the Participant's Handhl)l.k.

5. Prepare an additional tlipchan with feedback guidelines for the "pro\'idcr" :md the .. ..::llcnr..in the role plays (see belo\\').

Role-Play Feedback

* "Provider": Which counseling skills are youtrying to apply? What do you thmk you aredoing well? What do you think you canimprove on?

* "Client": Is the "provider" addreSSing yourneeds? 00 you feel like you are being heard?Are there questions that you want to ask orthings that you need to say that you do notfeel you can? Why?

6. Post the client proftle flipcharts from Session 6 where all panicipants can ~cc them.

EngenderHealth Comprehensive Counseling for Reproductive Health-Tra'ners '.1anua! 159

PP.EVIOUS PAGE BLA,\r\

Session 29

TimeTraining ActivitiesVariable,

depending onthe needs ofthe participants;a IlllllIffiUffi

of 4 hours

Time(minimum)

A. Small-group work .. _. . . . . . _ _ 30 min.

B. Role plays/feedback (1 st round) _ 30 min. per group;

20 min. role play, plus 10 min. feedback

(2 hours, 30 min., total for all1ive groups)

C. Role plays/feedback (2nd round) .. , ' . , . , , , . ' .. _.. , . 45 min.

(15 min. preparation,

plus 30 min, role play and feedback)

D. Summary/discussion _.. ' _, , , , _. , 15 min.


Session 29


Introduction

Counseling practice time can be structured in many ways, Factors will include the numocr ('Ifparticipants, the participants' skill levels. the amount of time 'lY<lilable. whether participant'. arestaying overnight at the workshop venue (which allow~ for preparation and practice time In thee\'enings). and \vhether a clinical practicum site is a\'ailable. The training te;lll1 will need todetermine which approach to counseling practice best tIts the participant',' needs and circumstances.

A counseling practicum (i.e .. in a clinic setting with actual client~ I j, the he,t practice Oprl'rtunity for participants and should be arranged. if at all possible. The counselmg practicull1would be held at a nearby service setting. When working with actual clients. a member of thetraining team or an experienced pro\'iuer frum the ~ef\'ICe ~ite (who i~ fc!miliar with the prinCiples of the training) nIl/st monitor each of the partIcipants while he or she is counselm~,

Clients must be asked for their permission to he counseled hy a trainec and to h:1\e nhsefl.erspresent. Allow plenty of time for discussion afterward. hack at the workshop \enue

If a practicum is not possible. the counseling practice can he conducted through rok play~.

Depending on the option chosen for counseling practice during the training (i,e .. 'arne or different groups of participants. with same or different client profile" I. you will Je.:iJe h0\\ W

assign groups and client profiles for these two final counseling practice ses.;ions.

Once the assignment of groups and profiles has been determined. the sClJuence of acri\ities IS

basically the same:

I. Allow preparation time for the participants. in their role play groups

2. Conduct the first round of role plays with all other participant,> ob~er\'lng:. and gl\Cfeedback (see first bullet. below)

3. Conduct another round of role plays ("ee secoml bullet. hetow I. with time for prep:tr;ltionbefore and feedback after

4, Summary discussion

The de\'elopment of client profiles \\as intended to ensure that the participants become familiar with a range of SRH problems and concerns during this training. This training was als(1designed to allow for numerous opportunities for the participants to praeticr.:: spccitlc counseling skills throughout the workshop. (By this time in the training. all of the participant'. shouldhave had a chance to do a practice role play at least once.) Therefore. consider the followingpoints when planning how to use your time for the final counseling practice sessions:

• For all participants to learn about the range of issues and needs to address in integratedSRH counseling. in the first round of role plays each client profile "team" shl1uld do J

demonstration role play while the rest of the participants observe. The discu~sion can thenfocus on issues and content of counseling for particular clients and for particular needs. aswell as counseling skills.

EngenderHealth Comprehensive CounselIng for Reproduclive Healt'1-Tra:ners' ~.~a:lual 161

Session 29

• To permit more participants to get practice with cowlselinr; skills, the second round of roleplays should be conducted concurrently (i.c., with all groups practicing at the same time).The number of concurrent groups would be determined by the number of training teammembers, since you must have a member of the training team to observe each role playand facilitate feedback. Depending on how much time is available, these concurrentrounds can be repeated several times, giving many more participants a chance to practicecounseling skills.

~ij


1. Explain the structure and timing of the counseling practice. For role plays, explain that eachgroup will have 20 minutes to conduct their role play of the entire counseling session, with10 minutes for feedback.

2. Post and briefly review the feedback guidelines f1ipchart (or refer the participants to pages131 and 132 in their handbook).

3. Divide the participants into five groups and assign client profiles.

4. Instruct the participants to use the remaining time to prepare for their role plays, in theirrole-play groups.

Activity B: Role plays/feedback (2 hours, 30 minutes)

1. Ask for a group to volunteer to begin the role plays. Before the role play begins, brieflyreview the client profile for that role play (from Session 6).

2. Have the group conduct the role play. (20 minutes)

3. Facilitate feedback, referring first to the "provider" and "client" role-play feedback flipchart.Then refer to the "Observation and Feedback Guide" tor comments from other participants.(10 minutes)

4. Repeat Steps 1, 2, and 3 for the remaining four groups. (2 hours)

Activity C: Role plays/feedback (45 minutes for each "round")

1. Assign new client profiles. (Putting participants into new groups is optional.) Spread thegroups around the room, or send some into break-out rooms, since they will all be conducting their role plays at the same time.

2. Ask the participants to briefly prepare for a role play with the new client profile. (j 5 minutes)

3. Ask each group to begin their role play. A member of the training team must be with eachgroup and should stop the role play after 20 minutes.

4. Have the training team member with each group facilitate feedback, using the "provider"/"client" sheet first and then the "Observation and Feedback Guide." (10 minutes)

5. Conduct as many more rounds of concurrent role plays as time permits. (45 minutes foreach round)

Activity D. Summary discussion (15 minutes)

Ask participants (and trainers) to summarize the most important things that they learned fromthese counseling practice sessions.


Session 30Meeting Providers' Needs and Overcoming Barriers

to Offering Integrated SRH Counseling

Objectives

• To describe three areas of the needs of health care staff and gi\"c examples (1f how the:-capply to integrated SRH counseling

• To identify barriers to providing integrated SRH counseling in the work setting and stLHe~le'

for overcoming those barriers

• To name at least two strategies for saving time in counseling and to explain how the:-;: .:-an beapplied in the participants' own work setting

Materials


Advance Preparation

I. Revie\v Session 30 in the Participant's Handbp0k (page 1331.

2. Prepare a flipchart entitled "The Needs of Health Care Stafr:' listing the thrce L'atcgnflc~

(Activity A).

3. Prepare at least two two-column flipcharts for listing barriers to integratcd SRH .::oun:-clin::and strategies for overcoming barriers (see Activity B and the Trainer,,' Tool. page, 166 [(I

167). Make the "strategies" column wider than the "barriers" column"

4. Review the Trainers' Tool (page 168) for ideas for facilitating the discussion l~n '[ra[e~!e~ [('overcome barriers to integrated SRH counseling L-'\.cti\"ity Cl.

Time

Time45 minutes

EngenderHealth

Training Activities

A. Presentation " "" """ "." " .

B. Brainstorm 5 min.

C. Discussion................................. .. 25 min.

D. Presentation 10 min

Comprehensive Counseling for ReprodUC!lve Healt~-Trainers Mai\'Jai 163

Session 30


Barriers to IntegratedSRH Counseling

Activity A: Presentation (5 minutes)

1. Explain that, having faced a bit of the reality of integrated SRH counseling through thecounseling practice, the participants should consider what providers need if they are to beable to offer effective counseling and how they can overcome bmTiers that might exist orproblems that could occur.

2. Post the prepared flipchart on the needs of health care staff, briefly describing the threecategories and why they are important (see Parti.cipant 'sHandbook, page 134). Note to theparticipants that you will return to these categories a hit later in the session.

The Needs of Health Care Staff

.. Facilitative supervision and manaqement

.. Information, training, and devE,opment

.. Supplies, equipment, and infrastructure


1. Post the two-column prepared flipcharts on barriers (see below).

Strategies forOvercoming Barriers

1-----------+----

L Ask the participants to think about what might make it difficult for them to provide integratedSRH counseling when they get back to their work sites.

3. List the participants' responses in the barriers column.


1. Starting with the first barrier on the list, ask the participants which needs category this fallsinto.

2. In the right-hand column, write "F" for "facilitative ... ," "1" for "information ... ," or "S" for"supplies ... ," depending on the participants' discussion.

3. Then ask what could be done to solve this problem or overcome this barrier. Note that thetype of need this barrier reflects could give them a clue about how to overcome that barrier.After a brief discussion, summarize the participants' ideas in the right-hand column (seeTrainers' Tool, pages 166 to 167, for examples).

4. Continue the same procedure for the rest of the barriers.


Session 30

Note: Admmistrators and supcn'isors must addres:- the need to moti\ak and reward pW\1dcr,for making the changes that may he necessary to pnniding integrated SRH Loun~eling. TheTrainers' Toolan page 168 lists 10 ideas for motivating staff: these l11<.ly be duplicated and

distributed to the administrators and superrisors \\'ho participate in thi" tr::lIning.

Activity 0: Presentation (10 minutes)

J. Note that "not having enough time" is a constant theme in counseling associated with an;.kind of health care. This is so for a number of reasons. over which many pro\lders havevery little control. This discussion \-vill focus on the things that We? cun do to make the he"tuse of time in integrated SRH counseling.

2. Give a brief presentation on the strategies for saving time noted in the [""entia] Idea" onpage 133 of the Participant's Handhook. Some of these may already haVe been Cl1\ereJduring the brainstorm and discussion. so just rC\'iew them brietly.

." Training Tip

One strategy that is out of the pro\"iders' controL hut th~lt could tX'addressed through this training. is to promote greater "UppOI1 for integrated SRH counseling from program managers and superyjsor.... Fnrexample. if managers and supenisors understand thc 1I1lpol1ancc or"the extra time needed to do ,ill adequ:itc risk as"essmenl. they mightadjust some of the \vorking conditions that limit timc for coun"cling.(Presumably. some managers and supcn'isors attended this training. I

AIternati \ ely. a shaner \'cfsiL)[1 of lhl.' work... hop ha.... becn Je \ell1f>cJfor program managers and supen'isors. both to foster Octter "upen'lsian for trainees once they return to their work sites and to cncouragcgreater support for implementing changes that may oc necessary forthe provision of quality counseling.

EngenderHeaJth Comprehensive Counseling for Reproductive Heatth-Tra;ners' Manual 165

Session 30

Trainers'Tool

Here are some examples of barriers that providers may identify and possible strategies toaddress those barriers. (Note: These should not be presented as "the answers," nor shouldyou try to cover all of these barriers and strategies.) Strategies need to be developed thataddress the specific barriers in different service sites or programs.

F '" Facilitative supervision and ma.nagement

I Information, training, and development

S Supplies, equipment, and infrastructure


Lack of time for counseling F:

• Clinic flow is reorganized to use time more efficiently andfree up staff for couns,eling.

• Staff who are assigned to counseling are not required todo other tasks.

• Frontline staff are involved in intake and in groupeducation, to cover basic informational tasks of counseling.

(The strategies depend on the nature of the problem,but many of them are Influenced by administrators andsupervisors.)

Lack of space to ensure privacy F/S:

• Large rooms (e.g., waiting areas) can be partitioned off orcurtained to provide visual privacy.

• One area of a large room can be set aside, with chairsarranged far enough away to provide lis~enjng privacy.

• Multiple usage of semiprivate spaces (e.g., examiningrooms or administrative offices) that are not always in use.

Lack of support from co-workersand supervisors for changesnecessary (e.g., space and time)

Lack of awareness amongother staff

F/I:

• Supervisors need to explain to the entire staff aboutthe importance of counseling and the changes that maybe necessary.

• Supervisors will likE~ly need to be oriented to theimportance and needs of counseling.

• Other staff can also be oriented about the importance ofcounseling and their own roles.

F/I:

• Supervisors need to communicate to all staff about theimportance of counseling.

• Orientation programs should be conducted for the entirestaff.

(continued)


Session 30~~~-~~-~~--~---~-------~---~------------_.~

Trainers' Tool (continued)


Embarrassment about raisingissues of sexuality

Reluctance to identify needsthat cannot be met on-Site

Pressure from administratorsto meet service-delivery targets

EngenderHeallh

Strategies for Overcoming Barriers

F/I:

• Supervisors reinforce the importance of raising Issues ofsexuality. acknowledge that it can be embarrasSing torproviders, and help with problem solving (eg.. through r:::;:eplaying).

• Follow-up to training should address this issue (w:le~nerproviders mention It or not) and provide relnlorcemen: io'overcoming the embarrassment.

• "Peer support groups" of providers who have 9;):18 :",r:)'..:;rthe training can help each other by acknowledgl~g tha:embarrassment is normal and by providing tips tor getln;;over it.

F/I:

• Information should be provided about where sen:ices areprovided off-Site.

• Supervisors need to motivate providers to utilize referralsystems.

F/I:

• Supervisors and administrators need to be or,ented !c t'lebenefits of meeting clients' needs (as opposed to meet"';!'"targets").

• Administrators and supervisors need to be clear about thepurpose of service-delivery ..targets" for planning pljipcsesand not impose them as "quotas- for Individual prcW!jes

Comprehensive Counseling tor Reproductive Health-Trainers 'r~anua, 167

Session 30

Trainers'Tool

Top 10 Ways for Administrators and Supervisors to Motivate Staff

1. Personally thank employees for doing a good joh--one-on-one, in writing, or both

in a timely way, often, and sincerely.

2. Take time to meet with and listen to your staff.

3. Provide specific and frequent feedback to staff about their perfonnance, being sure

that performance expectations and standards have been clearly explained. Support

them in their efforts to improve performance.

4. Recognize, reward, and promote high performers, hased on clearly stated performance

expectations; handle low or marginal performers so that they improve or leave.

5. Keep staff infomled about how the organization is doing, about upcoming services or

products, about strategies for being competitive. about the organization's financial

position, and about any new policies, among other things.

6. Involve staff in decision making, especially in decisions that affect them, as involve

ment leads to commitment and ownership.

7. Give staff an opportunity to learn new skills and to develop, and encourage them to do

their best.

8. Show all staff how you can help them meet their work goals while achieving the

organization's goals. Create a partnership with each employee.

9. Create a working environment that is opel!. trusting. and fun. Encourage new ideas,

suggestions, and initiative. Learn from, rather than punish for, mistakes.

10. Celebrate successes-of the organization, of the department, or of individual staff

members. Take time for team~building and morale-building meetings and activities. Tn

short, be creative.


Session 31Individual Plans for Applying

What Was Learned in This Training

Objectives

• To identify three changes that the participants want to make in their work immedla[el~ Wimplement what they have learned in this training, and explain why

• To make action plans with specific activities. barriers that might he encountered. and str.1tegies for overcoming them

Materials


• Copies of the "Action Plan Framework" (from the Particiranr'~ Handhook 1~(1ne fClr e~h.'hparticipant

• Flipchart of "Barriers and Strategies" from Session 30• Daily wrap-up f1ipcharts

Advance Preparationl. Review Session 3 I in the Participant's Handbook (page 135 J.

2. Make enough copies of the "Action Plan Framework" (on page 137 of the Pa[[]cir.1nr'~Handbook) to have one for each participant.

3. Post all of the Daily Wrap-Up flipcharts where the participants can sec them.-+ If you have access to a copying machine during the training. make a copy of each pam'::lpant's completed action plan before the end of the workshop. Return the Original rn the 11ar

ticipanL and keep the copy for use during the follow-up \i.~ib {sce SessJon 321. If this IS notpossible, keep the original action plan..;. make copies later. and return the originals to theparticipants as soon as possible.

Time


A. Introduction .

Time

. 5 min.B. Individual exerCise 30 min .C. Plenary . .......... 20 min.

EngenderHealth

D. Summary , 5 min.

ComprehenSive Counseling for Reproductive Health-Trainers' P/'anuai 169

Session 31



Review the training goal and objectives (Session I) and the purpose of integrated SRH

counseling (Session 2).

Activity B: Individual exercise (30 minutes)

1. Distribute the "action plan framework" handout, and describe it as a place to record:

• Specific action to be implemented immediately

• Why you want to make this change

• Barriers that might be encountered

• Strategies for overcoming barriers

2. Review the f1ipcharts from the daily wrap-up sessions, with the participants' ideas about

how they can apply what they have learned in their work sites.

3. Ask the participants to identify (to themselves) three concrete actions they would like to

implement when they get back to their work site, bilscd on what they have learned in this

training. Then, have each participant fill in all four columns of the action plan framework.

Explain why it is important for them to say why they want to implement each action (see

Essential Ideas on page 136 of the Participant's Handbook). Note that the "barriers/strate

gies" flipcharts from the previous session should give them some concrete ideas for this.

(20 to 25 minutes)

Activity C: Plenary (20 minutes)

1. Ask each participant to briefly share his or her three concrete actions, why he or she wants

to make those changes, the barriers he or she may encounter, and strategies for overcoming

these barriers.

2. Tick off the barriers and strategies noted hy the participants on the f1ipchart from the. .

prevIOus seSSlOn.


1. Collect the participants' action plans. Have them copied, ideally before the participants

leave. If this is not possible, explain to the participants that the action plans will be returned

to them as soon as feasible.

2. Ask the participants what similarities and differences they noted in each other's action plans.

3. Point out any patterns that emerged from the "b:uriers/strategies" that the participants

identified.

4. Note that the next and final session will discuss follow-up strategies, which include ways of

checking to see how they are doing in carrying out their action plans.

170 ComprehenSive Counseling for Reproductive Health-Trainers' Manual Engen derHealth

Session 32Training Follow..Up

Objective

• To describe the follow-up plans of the host institution. of the participants' own m~tJlutlon~'.and of the trainers

Materials~one needed

Advance Preparation1. Review Session 32 in the Particip'.lIl!'s Handbook Ipagc 139J.2. If plans for follow-up and evaluation activities were not made prior to the start of the \\Nk

shop (see "Before the Training Coursc" in rhc Introuu\.:tlOn for [he Traincr~. !'.I;C Xi \.discuss follow-up and evaluation with the host institutions for tim training prJL1f k' thi';session and determine what follow-up will be c(lnducted. by whom. and when.

3. Arrange for a representativc of thc host institution to address the group about foll,m -up ,melevaluation plans.

Time


A. Presentation .B. Presentation/discussion .

Time

. 15 rr;"

EngenderHeallh Comprehensive Counseling for Reproductive Health-Trainers ')lanual 171

Session 32


Activity A: Presentation (15 minutes)

Describe the training follow-up plan. This may include follow-on or in-service workshops to

focus on specific content areas for SRH counseling, as well as technical assistance site visits

to see how the participants are doing in implementing thei.r action plans, to provide guidance

for further development of skills, and to assist with problem s.olving.

Activity B: Presentation/discussion (15 minutes)

1. Have the host institution representative go into as much detail about follow-up and evaluation

plans as he or she is able.

2. Ask if the participants have any questions.

» Training Tip

Research has clearly shown that one-time trainings with little or no

follow-up have a very limited impact. The commitment to follow-up

by the host institution, the trainers, or both mllst be negotiated before

this training is scheduled. This may include regular site visits to the

participants' workplaces, to follow up on their progress in imple

menting the action plans and to provide technical assistance for the

further development of their skills and problem-solving abilities (see

"After the Training Course" in the Introduction for the Trainers,

page xxv).

The trainer can start this session with Activity A, but a representative

of the local host institution should go into detail in Activity B. The

participants will need to start looking to tIllS institution a<; the coordi

nator for follow-up activities and assistance.


Session 33Workshop Evaluation and Closing

Trainers' Objectives• To administer the self-assessment posttest• To n'aluate the participants' impressions of the training and to get "ugge.;tions for impro\

ing future \\"orkshops

• To fonnally thank all involved in this workshop. to wish C\'cryone well. and tel c]o,e tn.:proceedings

Materials

• CopIes of the self-assessment posttest (one per particlpam)• Corrected copies of the participants' self-assessment pretest:.-• Copies of the eval uation form (one per participant)• Certificates of participation (one per participant}

Advance PreparationI. Identify and im'ite guests for the closing ceremony,2, Make enough copies of the self-assessment posttest to haw one for each partlcipJ.nt.3. Make enough copies of the evaluation form to have one for each partIcipant.-1-. Prepare a certificate of participation (as appropriate for each --c{lmg) for each panicipalll.5. Identify one of the participants to give closing remarks on hehalf of the participanb.

(Preferably. this would be done earlier in the day.'6, Summarize the workshop for any guests attending the clming ceremony (thh C~ln be June

by a participant as well). and prepare the guest-; to give brief (omment:-.. If pnssibJe. in\itethem to attend the entire afternoon session. when participant" will be di,cu;;sing actlClnplans and sharing with others what they learned.

Time

1 hour. 30 minutes Training Activities

A. Posttest .... " ..

B. Evaluation , , .. , .

C. Closing ceremony .. , .. , .... '

Time

, .. ,.45 min.

. " , 15 min.

., .. ,., , 30 min.

EngenderHealth Comprehensive Counseling for Reproductive Health-TraIners' '>1a''lual 173

Session 33


Activity A: Posttest (45 minutes)

1. Administer the self-assessment posttest. (30 minutes)

2. When everyone is finished, review the answers to the self-assessment posttest, while the

participants correct their own papers. (10 minutes)

3. Hand back the pretests, so the participants can compare their scores before and after

the workshop. (5 minutes)

4. Collect all self-assessment posttests, so the scores can be recorded for pretest-posttest

analysis. Remind the participants of your commiuncnt to keep scores confidential.

(Participants can keep the pretests.)

Activity B: Evaluation (15 minutes)

I. Distribute the evaluation forms.

2. Allow 15 minutes for the participants to complete them.

3. Collect all copies of the evaluation.

Activity C: Closing ceremony (30 minutes)

Conduct a closing ceremony appropriate to the setting. Thank the participants and celebrate

the completion of the training.


EngenderHealth

Appendix ASample Training Agendas

Comprehensive Counseling for Reproductive Health-Tra'ners· Manual 175

Sample Training Agendas

Agenda for the Training of Providers: Six Days

Day and Time

Day 1

Morning

Afternoon

Day 2

Morning

Session

Welcome and Introduction

2 Defining Sexual and Reproductive Healthand Integrated SRH Counseling

3 Why Address Sexuality?

4 The Problem Tree-Roots and Consequences ofSRH Problems

Total time

Lunch break.

After-Lunch Warm-Up2

5 Supporting Clients' Informed and Voluntary DeCisionMaking

6 Client Profiles for Sexual and ReproductiveHealth Decision Making

Dally Wrap-Up

Total time

Daily Warm-Up

7 Clients' Rights, Client-Provider Interaction, andCounseling

8 Counseling Frameworks: Option A. REDI

or

8 Counseling Frameworks: Option B. GATHER

9 Rapport-BUilding-Respect, Praise, andEncouragement

Total timeLunch break

Time

1 hOur. 15 minutes

1 ho\.J~

1 hour

4 hours. 15 minutes'

15 mlilutes

1 hour

1 hour

30 minutes

3 hours1

15 minutes

1 hour. ~5 m,nu,es

1 hour

1 hour

45 minutes

4 hours '

(continued)

EngenderHealth Comprehensive Counseling for Reproductive Heaith-Trainers' \1anuaJ 1n

F;rt\~OUS P,~GE BLANK

Appendix A

Agenda for the Training of Providers: Six Days (continued)

Day and Time Session Time

Day 2 (continued)

Afternoon 10 Provider Beliefs and Attitudes

11 Sexuality

12 Vanations in Sexual Behavior

Daily Wrap-Up

Total time

Day 3

45 minutes

1 hour

45 minutes

15 minutes

3 hours'

Morning

Afternoon

Daily Warm-Up

13 Building Rapport with Male Clients and withAdolescent Clients

14 Asking Open-Ended Questions

15 Listening and Paraphrasing

Total time

Lunch break----

16 Using Language That Clients Can Understand

15 minutes

1 hour, 15 minutes

1 hour, 30 minutes

45 minutes

4 hours'

1 hour, 15 minutes

17 Using Visual Aids to Explain Reproductive 45 minutesAnatomy and Physiology

18 Introducing the Subject of Sexuality with Clients 45 minutes

Daily Wrap-Up 10 minutes

Group assignments for Session 21 (see Trainers' Manual) 5 minutes

Total time 3 hours, 15 minutes1

Day 4

Morning Daily Warm-Up

19 The Risk Continuum

15 minutes

1 hour

2 hours, 30 minutes

15 minutes

3 hours1

Afternoon

20 Exploring the Context of Clients' Sexual Relationships 45 minutes

21 Information-Giving in Integrated SF:H Counseling 1 hour

22 Risk Assessment-Improving Clients' 45 minutesPerception of Risk

Total time 4 hours'

Lunch break

23 Counseling Practice I

Daily Wrap-Up

Total time

(continued)


Appendix A

Agenda for the Training of Providers: Six Days (continued)

Day and Time

Day 5Morning

Afternoon

Day 6

Morning

Afternoon

Session

Daily Warm-Up

24 Gender Roles

25 The EHect of Power Imbalances on SRHDecision Making

26 Helping Clients Make Decisions-CounselingPractice II

27 Helping Clients Develop an Implementation PlanCounseling Practice III


28 Helping Clients Develop Skills in PartnerCommunication and Negotiation

29 Counseling Practice-Final [beginning)

Daily Wrap-Up

Total time

Daily Warm-Up

29 Counseling Practice-Final [continued]

30 Meeting Providers' Needs and Overcoming Bamersto Offering Integrated SRH Counseling


31 Individual Plans for Applying What Was Learnedin This Training

32 Training Follow-Up

33 Workshop Evaluation and Closing

Total time

Time

15 minutes

50 minutes

45 minutes

1 hour. 30 m,l!l.leS

45 mlnu:es


1 hour

1 hour. 30 mi'lU!eS

3 hours'

3 hours

45 minutes


1 hour

30 mlnu~es

1 hour. 30 mn:Jtes


1 All "total times' Include lime for a IS-minute break. Trainers Will deCide when to schedule tnese breaKS. :;asej [},., i.:-caipreferences.

2 An after-lunch warm-up is scheduled for the first day. to help 'break the Ice' and encourage communlcalJQn among pame,·pants. You can select one of your favorite warm-ups for this session There are no other -af1er· 1uncn warm·ups- s.:ned"iedon lIle following days. because all of the after-lunch seSSions are highly mteracbve and 1n(ltr:Je grc-up a::..'tes .1 ~::"J \\aNto conduct additional warm-ups after lunch. you will need 10 adjust the schedule and extend tile [1'1'\i) aiio::ed ~c,r ~,e a~er-~G'

sessIOns.

EngenderHealth Comprehensive Counseling for Reproductive Heatth-Trainers Manual 179

Appendix A

Agenda for the Training of Frontline Staff: Two Days

Day and Time

Day 1

Morning

Afternoon

Day 2

Morning

Afternoon

Session

Welcome and Introduction (Session 1)

Defining Sexual and Reproductive Health and IntegratedSRH Counseling (Session 2)

Why Address Sexuality? (Session 3)

The Problem Tree-Roots and Consequencesof SRH Problems (Session 4)

Total time

Lunch break

After-Lunch Warm-Up"

Supporting Clients' Informed and Voluntary DecisionMaking (Session 5)

Sexual and Reproductive Health Decision Making(Session 6)3

Daily Wrap-Up

Total time

Warm-Up

Clients' Rights, Client-Provider Interacti~Jn, andCounseling (Session 7)

Counseling Frameworks, with Emphasis onRapport-Building/Greeting (Session 8)

Provider Beliefs and Attitudes (Session 10)


After-Lunch Warm-Up2

Information-Giving in Integrated SRH Counseling(Session 21)

Integrated SRH Counseling: A Demonstration4

Workshop Evaluation and Closing (Session 33)

Total time

Time

45 minutes

1 hour

45 minutes

1 hour

3 hours, 45 minutes1

15 minutes

1 hour

1 hour

30 minutes

3 hours'

15 minutes

1 hour, 30 minutes

45 minutes

45 minutes


15 minutes

1 hour

45 minutes

45 minutes

3 hours1

1 All "total times" include time for a 15-minute break. Trainers will decide when to schedule these breaks, based on localpreferences.

2 Select one of your favorite warm-ups for this session.

3This session should be based on Session 6, but will not involve the development of client profiles.

4This session will involve a demonstration role play based on the various counseling practice sessions that are part of thiscurriculum.

(continued)


Appendix A

Agenda for the Training of Administrators and Supervisors: Three DaysDay and Time

Day 1

Morning

Afternoon

Day 2

Morning

Session

Welcome and Introduction (Session 1)

Defining Sexual and Reproductive Health and IntegratedSRH Counseling (Session 2)

Why Address Sexuality? (Session 3)

The Problem Tree--Roots and Consequences ofSRH Problems (Session 4)

Total time

Lunch breakAfter-Lunch Warm-Up:

Supporting Clients' Informed and Voluntary DeCISionMaking (Session 5)

Sexual and Reproductive Health DeCISion Making(Session 6)'

Daily Wrap-Up

Total time

Daily Warm-Up

Time

45 minutes

1 hour

45 minutes

1 hour

3 hours. 45 minu1es I

1 hoc;r


15 m:n,,:esClients' Rights, Client-Provider Interaction, and Counseling 1 hour, ~5 ,....:'~;es(Session 7)

Counseling Frameworks (Session 8)" 45 minu!esProvider Beliefs and Attitudes (Session 10) 45 minutesTotal time 3 hours. 45 minutes 1

Lunch breakAfternoon After-Lunch Warm-Up'

Introducing the Subject of Sexuality With Clients(Session 18)

The Risk Continuum (Session 19)

Risk Assessment~lmproving Clients' Perception of Risk(Session 22)

Daily Wrap-Up

Total time

15 minutes

45 minJ~es

45 minLtes

15 minutes

3 hours'

(con1muedl

EngenderHeallh ComprehenSive Counseling for Reproduelive Heai:!r-Tra:ners '.'ar'~a' 181

Appendix A

Agenda for the Training of Administrators and Supervisors: Three Days(continued)

-----~-------~----.:....--

Day and Time

Day 3

Morning

Session

Daily Warm-Up

Information-Giving in Integrated SRH Counseling

(Session 21)

The Effect of Power Imbalances on SRH

Decision Making (Session 25)

Helping Clients Make Decisions and Develop

an Implementation Plan'

Integrated SRH Counseling: A Demonstration"

Total time

Time

15 minutes

1 hour

45 minutes

45 minutes

30 minutes


Lunch break ----.----------------

Afternoon After-Lunch Warm-Up2

Meeting Providers' Needs and Overcomill\l

Barriers to Offering Integrated SRH Counseling(Session 30)

Training Follow-Up (Session 32)

Workshop Evaluation and Closing (Session 33)

Total time

15 minutes

1 hour, 15 minutes

30 minutes

45 minutes

3 hours1

, All "total times" include time for a 15-minute break. Trainers will decide when to schedule these breaks. based on local

preferences.

'Select one of your favorite warm-ups lor this session.

3This session should be based on Session 6 in this book, but will not invol'ie the development 01 client profiles.

4This session can review both REDI (Option A) and GATHER (Option 81. but should emphasize the general principles of

counseling that both of these approaches share.

'This session should combine the main points 01 Sessions 26 and 271rom this book.

6This session will involve a demonstration role play based on the var\oiJS counseling practice sessions that are part of this

CUrriculum.


EngenderHealth

Appendix BDaily Warm-Ups and Daily Wrap-Ups

Comprehensive Counselmg for Reproductive Health-Tra:ners Marcuai 183

Appendix B

Daily Warm-Ups and Daily Wrap-Ups

Daily Warm-Up

Trainers' Objectives

• To help the participants refocus on their participatioll In the workshop

• To review the previous day's discussions and learning in tenns of the clIent's perspective

• To preview the day's sessions and learning objecti\'es

Materials


Advance Preparation

I, Prepare to conduct your fa\'orite icebreakers or other warm-up activities. in a 5-mmurc umt:frame. Short games. songs. or physical acti\ities can help participants get energizccl aIdfocused on being back in the workshop setting and mtcracting with fellow partlclpants, Y1,111

em also ask participants to lead the group in :-.ongs or :-hort group ;lct/\i tic:--.

2. Prepare one or two questions to ask the participants. to help them think ;lDout the prLl!lkJclients' perspecti\'es. based on the previoll'. day'.~ sc ...... iplls and di ... cusswn:-.. For exampie. l,lnthe day after the session on "Reflections on How We LC;,trned ahout Sexuality" I Ses"'ll,)D11). you might ask the participants. "How might each of the proftied clients have 1c.lrn;,>Jabout sexuality?" Similar questions can be asked about sexual ancl reproducti\e ri,:::h: .... theattitudes and beliefs statements. and the clients' reaction" to any of the exerCl<.es on counseling skills and steps later in the training.

3. Decide ho\\' to preview the clay's sessions, You may \\ant to refer the particir~il1t" tl) eachsession's Learning Objectives in their handhooks rthe hulleted item" preced ing the E ......entulIdeas}. or you may want W post session objccti\cs on tlipchart~ If you L'h(),h(: t(, rl,'~t

f1ipcharts. these will need to be prepared in advance,

Time15 minutes Training Activities Time

EngenderHeallh

A. Welcomelloglstlcs"., ,.,., .. ,.""."" .. "", 5 min,

B. Icebreaker,. ' , , . ' , .... ' , , , , , . , , , , 5 l";"lIn.

C. Discussion/presentation ,."."",. , , , , 5 min,

Comprehensive Counseling for Reproduclive Health-Trainers' \Ianc.a' 185

PREVIOUS P/\(;E BLAf'~K

Appendix 8

Daily Warm-Up Detailed Steps

Activity A: Welcome and logistics (5 minutes)

1. Welcome the participants back to the workshop.

2. Make announcements and address any "housekeeping" or logistical issues that need to bediscussed.

Activity B: Icebreaker (5 minutes)Conduct a short icebreaker.

Activity C: Discussion/presentation (5 minutes)

1. Briefly review the sessions of the previous day. Ask the prepared question(s) based on theprevious day's sessjons, to help the participants think about the profiled clients' perspectives.

2. Preview the day's sessions (as you determined during Advance Preparation).

Essential Ideas for the VVarm-Up

• The numerous role plays and practice sessions in this curriculum usually focuson the knowledge, attitudes, and skills of the participant who is playing the"provider." But equally important learning can happen for the person who isplaying the "client." Role-playing the client involves thinking about a client as awhole person and being able to understand how the lives of clients outside thefacility influence communication within the service-delivery setting.

• Thinking about the client's perspective can help providers to identify similaritiesbetween themselves and clients. Paying attention to similarities between clientsand providers can be as helpful as noticing the differences, since the things thatwe share help build a bridge of understanding and communication betweenclients and providers.


Appendix B

Daily Wrap-Up

Trainers' Objectives

• To recap the information and ideas covered during that day

• To identify one thing that each participant could do in his or her work to apply what he orshe learned today

• To provide feedback to the trainer about how well the \vorkshop is going. hSUe-- [hat rL'n131nunclear. and \vays to improve the workshop

Materials

• Flipcharr paper. markers. and tape

Advance Preparation

Before the first \\Tap-Up session. create two tlipcharts entitled ":\eed ... \h)[t: Di ....cu ...... illl1·· .mJ"How Can I Apply in \ly Work What I Ha\'l;:~ Learned Today')"

Time15 minutes Training Activities

A. Discussion .

Time

. .. 15 m:n

EngenderHeaJlh Comprehensive Counseling for Reproductive Health-Trainers Manua! 187

Appendix B

Daily Wrap-Up Detailed Steps

-+ Training Tip

These are suggestions for getting valuable feedback from participants at the end of each day. You may have other ideas andapproaches for the daily wrap-up; feel frel~ to try other exercises orvary your approach to asking these questions.

However, be sure to cover the last question, "What is one thing I cando to apply what I have learned from today's sessions?" This will beimportant to look back on for their "action plans" (Session 31).


I. Briefly review the topics covered in that day's sCSSiO:1S.

2. Ask the participants the following question. Encourage everyone to say something, but donot write this on a flipchart.

* What \vas the most important thing you learned from today's sessions?

3. Post the t1ipchart entitled "Needs More Discussion." ,'\sk if there arc any areas that remainunclear or that need more discussion. Note these areas on the flipchart.

4. Ask the participants the following question.

* What suggestions do you have for making things go well tomorrow?

Do not write their answers on a flipchart, but thank tbe participants for their comments andnote that you will try to follow the recommendations as much as possible.

-+ Training Tip

,\fter the first day, the "Needs More Discussion" flipchart will berevisited each day. Before asking if any areas remain unclear fromthis day. briefly review the list from the preceding days and ask\\/hich (if any) have been covered adequately by now. These can becrossed out; the others will remain on the list.

It is hoped that you will be able to address these unclear issues atsome point during the workshop. These "wrap-up" sessions are notintended to be used for that purpose, unless you find that there isenough time at the end of the day to do so

5. Post the flipchart "How Can I Apply in My Work What I Have Learned Today?" Then askthe participants:

* What is one thing that you could do when you get back to your work site to apply whatyou learned from today's sessions?


Appendix B6. List the participants' responses on the tlipchart. Do not write the ~arne ~Ul:,\\ er" more than

once. but make tally marks alongside each to indicate how many time" thlS an:,wer \\;bgIven.

»+ Training Tip

• Save the "How Can I Apply ... ·· tlipchan sheet.;, for each day. :\tthe end of the workshop_ during Session 31. refer back to theseideas from each day. to help the participants start working on theiraction plans.

• In asking for one idea from each partiCIpant about how to applywhat he or she has learned. one participant might ha\c an idea towhich en:ryone else will say. "Yes. r would do the same thing"\Vhile such a response could in theory he accurate and significant.it is important to encourage people to think independently. Thus.on the first day. you 111Ight put paniClpants imo pJ.lr" to di:,(u:--,this issue brietly and ask each pair to repol1. If you feel that thi, i:-not necessary to get a r:.ll1gc of ;1I1"wers. then hrain"tonl1ing work,well. too.

I Essential Ideas for the lrrap-Vp

• This daily recap is meant to help participants focu" on reali'-lic change:' thc~ c~:nmake immediately (i.e .. a.'> so()n as they return to worK) to cnhan.... e their cnmmunications and counseling with clients.

• Too often. tr<:linIngs end WIth actipn plans that nc\cr get applied be,:au:,c [ho;potential changes that participanh identify ::lfC too many. are too bif:" or requirethe approval of others If they are to happen. By identlfying (ine thing in ea..:hday's learning that participants r('(if/\ think they Gll1 do \\'hcn they return [l) ;h(,l~\\ork site _we hope to prcn ide a found"tiun for re~d ;jnt.! lastll1~ 1..'h~lnge ;jn,,] I, 'r"application of the ideas and approaches prc:-.cntcd 1I1 this traming:.

• It is important to be realistIC aboLlt what is expected from pro\"lder:-.. We ()ftcntalk about providers and what is expected of them as if they werc :-.up('rhull1anand should be able to prO\ide high-qualIty counseling to all clients at ;.\11 lIme:--.e\"en under the most ad\erse conditIOns. This daily exercise allows pro\"lder' Wha\'e more realistic expectations of themselves. which should help them J\oiJ

. becoming discouraged about implementing this training's approaches.~ //

EngenderHealth ComprehenSive Counseling for Reproductive Heaith-Tralne"s /,'an,,3, 189

EngenderHeallh

Appendix CPromoting Informed and Voluntary

Decision Making to Support Clients' Rightsand Address Clients' Needs

Comprehensive Counseling for Reproductive Health---Trainers' Manual 191

PREVIOu~ ~-\

Appendix C

Promoting Informed and VoluntaryDecision Making to Support Clients' Rights

and Address Clients' Needs

Presentation and NotesThe following are slides that can be used for presentations about how clients' informeJ anJvoluntary decision making about their sexual and reproductive health is rooted In hununrights. If you have access to an overhead projector. these can be photocopieJ onkl tr,m'rJ.rcncies: if no projector is available. the content of the slicks can rc copied 0nt0 f1irch,m-.Following the slides are notes. commentaries. and training suggestions that can re used to

supplement the information in the slides.

EngenderHealth

PREVIOUS P,;GE BLAr:K

Comprehensive Counseling for Reproductive Heallh-ira;ners ~.1anCial 193

Appendix C

Slide 1

PromotingInformed and Voluntary

Decision Makingto Support Clients' Rights


EngenderHealth, 2003

EngenderHealth Comprehensive Counseling tor Reproductive Health-Trainers· Manual 195

PREVIOUS PAGE BLAr~i\

Appendix C

Slide 2

During this presentation ...

• 60 women will die from preventablecomplications of pregnancy and childbirth

• 228 girls will undergo female genital cutting

• 240 women in the United Sta.tes will bebattered by their partners

• 250 women will contract HI\/

Source: Panos Institute. 1998. Using human rights to gain reproductive rights. Panos BriefingNo. 32, London.

196 Sexual and Reproductive Health Counseling-Trainers' Manual EngenderHealth

Appendix C

Slide 3

Sexual and ReproductiveHealth Care Includes:

• Family planning information, counseling, and.services

• Prevention and treatment of sexually transmittedinfections (STls) and reproductive tract infections(RTls)

• Diagnosis and treatment of HIV and AIDS

• Antenatal, postpartum, and delivery care

• Health care for infants

• Management of abortion-related complications

• Prevention and treatment of infertility

• Information, education, and counseling onhuman sexuality, SRH, and parenthood

• Diagnosis and treatment of reproductive systemcancers

Source: ICPD Programme of Action, 1994. paragraphs 7.2, 7.3. and 7.6.

EngenderHealth Comprehensive Counseling for Reproductive Hea'lh-Trainers '.~anual 197

Appendix C

Slide 4

Reproductive Rights: ICPD, 1994

The rights of individuals and couples:

• To decide freely and responsibly the number,spacing, and timing of their children

• To have the information and means to do so

• To attain the highest standard of sexual andreproductive health

• To make decisions concerning reproduction freeof discrimination, coercion, and violence

Source: ICPD Programme of Action, 1994, paragraph 7.3.


Appendix C

Slide 5

Reproductive and Sexual Rights:FWCW, 1995

The human rights of women include:

• Their right to have control over and decide freelyand responsibly on matters related to their sexuality,including sexual and reproductive health, free ofcoercion, discrimination, and violence.

Source: Fourth World Conference on Women Platform for Action, 1995. paragraph 96.

EngenderHealth Comprehensive Counseling for Reproductive Health-Tramers' M3r1Uai 199

Appendix C

Slide 6

Considerations for MakingReproductive and Sexual Rights

a Reality

• What rights are "officially" reco~Jnized andprotected by law?

• How do public awareness and perceptions reflectthe differing perspectives of government, religion,local communities 1 and individuals?

• What is the status of women? Of youth?

• How do customs and traditions influence theexercise of existing rights?


Appendix C

Slide 7

Clarifying Terms

• Informed consent: A medical, legal, and rightsbased construct whereby the client agrees toreceive medical treatment, to use a familyplanning method, or to take part in a study(ideally) as a result of his or her informed choice.

• Informed choice: An individual's well-considered,voluntary decision based on options, information,and understanding.

• Informed and voluntary decision making:Informed choice, applied to any health caresituation.

EngenderHeaJth Comprehensive Counseling tor Reproductive Heallh-Tra:ners Manual 201

Appendix C

Slide 8 -==~====

Why Informed and VoluntaryDecision Making

for Reproductive Health?

• Medical ethics/human rights

• Policy requirements

-Quality of care: client satisfaction

• Program benefits confirmed by research

• Practical benefit to clients


Appendix C

Slide 9

Informed and VoluntaryDecision Making

Is a Good Program Strategy

Research tell us that informed choice leads to:

• Better method use and client compliance withtreatment regimens

• Continued method use

• Satisfied clients, who in turn are good programpromoters

EngenderHealth Comprehensive Counseling for Reproductive Heatlh-Tramers· Manual 203

Appendix C

Slide 10 -~=-==-==-===~~

Research Also Tells Us That...

Giving people a choice of family planning makes adifference.

• Contraceptive use is highest when a variety ofcontraceptive choices are readily available (Ross et

al. , 2002)

• When people get the method they prefer, they aremore likely to continue using it (Pariani, 1991)

• Increased continuation contributes more tocontraceptive prevalence rates than an increaseIn new users (Jain, 1989)


Appendix C

Slide 11

More evidence from research ...

One of the major reasons why clients discontinuepills and injectables is that they are not adequately

informed about side effects.

Source: EngenderHealth studies in Cambodia (2000) and Nepal (2001)

EngenderHealth Comprehensive Counseling for Reproduchve Health-Trainers· Manual 205

Appendix C

Slide 12

Consequences of Not EnsuringInformed Choice

in Family Planning

• Improper method use, resulting in unintendedpregnancy

• Fear of and dissatisfaction with side effects,leading to discontinuation

• Failure to recognize serious \Narning signs,leading to health risks

• Dissatisfaction with quality of interaction orwith method given, leading to drop-out, poorword of mouth, and low use of services


Appendix C

Slide 13

And Yet ...The Reality of Informed andVoluntary Decision Making

in Practice

Individuals' ability to exercise their rights to makeinformed and voluntary family planning andreproductive health decisions is hindered by:

• Social and cultural factors

• Laws and policies

• Service-delivery practices

• Providers' attitudes

• Resource constraints

EngenderHealth Comprehensive Counseling for Reproductive Health-Trainers ',1anual 207

Appendix C

Slide 14

Research and ObservationTell Us:

Counseling often does not meet clients' informationaland emotional needs

• Incomplete information or information overload

• Little or no preparation for side effects

• Failure to address fears and concerns

Many providers lack

• Good communication skills

• A client-centered approach

• The knowledge that they need for effectivecounseling

• Comfort in discussing SRH

• Adequate management and supervisory support


Appendix C

Slide 15

An Expanded ConceptualFramework

Basic elements that support informed andvoluntary SRH decision making:

1. Service options are available.

2. The decision-making process is voluntary.

3. People have appropriate information.

4. Good client-provider interaction, includingcounseling, is ensured.

5. The social and rights context supportsautonomous decision making.

Source: EngenderHealth. 2003. Choices in family planning: Informed and voluntary deciSIOnmaking. New York.

EngenderHeallh Comprehensive Counseling for Reproducllve Health-Tra:ners '.~anual 209

Appendix C

Slide 16 =--:-======

Influences AffectingInformed and Vc~luntary

Decision Making in SRH

Individualand

community

Policy ~----~Servicedelivery


Appendix C

Slide 17

Individual and CommunityFactors...

That Affect Decision Making

• Sociocultural expectations and beliefs

• Rights context and individual status

• Sources and quality of information

~ Family and friends

~ Public information and education:media campaigns, articles, andradio or TV broadcasts

>- Outreach workers

EngenderHeallh Comprehensive Counseling tor Reproductive Health-Tra,~ers '.lanuai 211

Appendix C

Slide 18 -========

Service-Site Factors...


• Providers' attitudes, knowledgH 1 and skills in SRH

• Quality of counseling and time allocated for it

• Client education materials

• Method and service options available on-site

• Fee structure for SRH services


Appendix C

Slide 19

Policy and Program Factors...


• Policies concerning an individual'sright to access SRH services,regardless of age or marital status

• Laws concerning an individual'sdecision-making rights with respectto SRH care

• Integration of SRH services

• Targets, quotas, or performance-basedfunding in family planning services

• Per-case referral or provider paymentsin family planning services

EngenderHeallh ComprehenSive Counseling for Reproductive Health-Trainers '.'anua 213

Appendix C

Slide 20

Applying the ExpandedFramework:

Fostering a Supportive ,Social, Policy,and Service-Delivery Environment

for Informed and VoluntaryDecision Making

• Help service providers to consider and addressclient issues that extend beyond the clinic

• Join or create alliances to advocate for social andpolicy change

• Ensure access to service options

• Increase individual and community participation


Appendix C

Slide 21

The Value of Informed andVoluntary Decision Making

Supporting clients' informed and voluntarydecision making:

• Helps people exercise their right to makeand act on their own decisions about theirhealth and reproduction

• Helps meet clients' needs and increaseclients' satisfaction

• Helps meet programmatic goals

EngenderHealth Comprehensive Counseling for Reproduc!lve Health--T'alne,s Manual 215

Appendix C

Supplementary Notes and Commentaryfor the Presentation

Slide 1

Notes to Slide 1:

PromotingInformed and Voluntary

Decision Makingto Support Clients' Rights


En geMerHealth , 2003

Slide 2

During this presentation ...

• 60 women will die from preventablecomplications of pregnancy and Childbirth

• 228 girls will undergo female genital cutting

• 240 women in tile United States will bebattered by their partners

• 250 women will contract HIV

5c--,~ ::>~ f"IS."T~~" .?;"~ _'srv; -".........,;j_~ ~qrr~ :-.: ;.I"" '-fCr-:~-r~i1 -,7'5.. ::11.-"::"1 ~c ...·,._;

~..:~? :..~

The obJectives of this session arc:

• To consider reproductiw and se.\ual rightsstipulated hy international conferences andagreements. and discus:,> ho\\ these rIghtsapply to the local situ;Jtion

• Tv define informed and \'oluntar;. deciswnmaking (informed choice I and explaIn hl~\\

it differs from infonl1ccl ccm,enl

• To descrihe three le\"c'ls of factors that influence informed and \1.)l~lllLlf\ (L:ci,i,~n

rnaking--(.'ornmunity and individual fact(lh.

policy factors. and sc[\icc-delin~ry factor,

• To dISCUss how infonned and \olunt;ll"\ dCI..'Ision making ~Ipplie, tn speCltic SRH need ...and ser.iccs

Notes to Slide 2:

• \\'hat do these numbers mean to u~.'

• How do reproducti\c and se\L1~lI rIf:ht~

;1pply IP th(:~c SHLl<lIipn~)

• Let LIS try to remember the indi\idu:.i1' represented hy these statjqics as we go throughthiS presentation.

EngenderHeafth Comprehensive Counseling for Reproducllve Heatth-Tra~ners' Manual 217

FREVIOUS PAGE BLANK

Appendix C

Slide 3

Sexual and ReproductiveHealth Care Includes:

• Family planning information, counseling. andservices

• Prevention and treatment of sexually transmittedinfections (STls) and reproductive tract infections(RTls)

• Diagnosis and treatment of HIV and AIDS

• Antenatal, postpartum. and delivery care

• Health care for infants

• Management of abortion-related complications

• Prevention and treatment of infertility

• Information, education, and counseling onhuman sexuality, SRH, and parenthood

• Diagnosis and treatment of reproductive systemcancers

S-aurcrrjCPDProgramme 01 AClion. 19')<1, paragrilp'1'S 7.2. I,j, ~f'lrj 7.6.

Slide 4

Reproductive Rights: ICPO, 1994

The rights 81 individuals and couples:

• To decide freely and responsibly the number,spacing, and timing of their children

• To have the information and means to do so

• To attain the highest standard of sexual andreproductive health

• To make decisions concerning reproduction freeof discrimination, coercion. and violence

SCure-G- ICPO PlOgramme 01 ~lOn, ' 9~, paragrai)h 7;:'

Notes to Slide 3:

This is a review of the list of services discussed in Session 2. Ask the group if they haveanything to add.

Notes to Slide 4:

"Reproductive rights embrace certain humanrights that are already recognized in nationalla\\/5, inl ernational human rights documents,and other consensus documents, These rightsrest on the recognition of the basic rights of allcouples and individuals to decide freely andresponsihly the number, spacing, and timing oftheir children and to have information andmeans to do so, and the right to attain thehighest standard of sexual and reproductivehealth .... land] the right to make decisionsconcerning reproduction free of discrimination, coercion, and violence."


Appendix C

Slide 5

Reproductive and Sexual Rights:FWCW, 1995

The human rights of women include

• Their right to have control over and decide freelyand responsibly on matters related to their sexuality,including sexual and reproductive health, free ofcoercion, discrimination, and violence

Slide 6

Notes to Slide 5:

One year after the International Conference ,mPopulation and De\'c!opment W3' held InCairo. the international communlt\ reaftlm1cdand expanded the rights articulatcJ In the CairoProgramme of Action to incluJe ~exual right:as well as reproducti\c right:-,

Notes to Slide 6:

• What is the status ot women? Of youth?

• How do customs and traditions influence theexercise of existing nghts?

Considerations for MakingReproductive and Sexual Rights

a Reality

• What rights are 'offlcially' recognized andprotected by law?

• How do public awareness and perceptions reflectthe differing perspectives of government. religion,local communities, and Individuals?

Reproducti\'c and sexual righb ,tIll ~lrt' .1 "f,)Ieign" cunccpt in many part..; t)f the \\l'rld F,lrrights to fed "real" for people. the~ necd t(l t>cdefined and presented In way..; that are cultural·Iy appropriate and meaningful t\.1 each ~r:-nn

These factors ..;hould he important when :-uch adefinition is being den~loped:

• \Vhat do people know of their rlghts 1 [f

pcopk arc not aware nf their r,~hb, lhe\' C.'crtainl) cannot excrci:-e them. Hl)W .lre [10:111:

perceived? .-\re they meant to benefit theindi\idU3P Do they threaten the family 1

• \\'hat are the customs and Iradltlt1nS that

influence the excrche of rcrroJuctlvc anJsexual rights: How c~m the~e ri~ht:-. be presented in \\'i1VS thaI reinforce tradItional

values? For example. respect and value for the family can be strengthened by gi\'ing coupie..;the right to decide \','hen they should have children and how many they should ha\c

• What are the different perspecti\'l,~s on rights') :\'ational go\Crnmenls, religion:- group..;. andcommunities may have very different perspecti\'es on issues of reprodu('ti\'C ;llld ,,;c,wal

rights. How do these perspectives influence the individu31's sense of what thelr n~hb are andwhat they mean?


Appendix C

Slide 7

Clarifying Terms

• Informed consent: A medical, legal, and rightsbased construct whereby the client agrees toreceive medical treatment, to use a familyplanning method, or to take part in a study(ideally) as a result of his or her informed choice.

• Informed choice: An individual's well-considered,voluntary decision based on options, information.and understanding

• Informed and voluntary decision making:Informed choice, applied to any health caresituation.

----~

Notes to Slide 7:

Much of the language of reproductive andsexual rights focuses on the right to makedecision~; "freely and responsibly." Thus, oneof the most concrete and significant ways inwhich we can support a rights-based approachto SRH is to support informed ("responsibly")and voluntary ("freely") decision making byindividuals and couples.

The concept of informed and voluntary decision making applies broadly to any health caredecisio[ and assumes that individuals haveboth the right and the ability to make theirown health care decisions. How does thisconcept relate to other similar concepts, suchas infol'l'IlCd consent and informed choice?

Informed consent: A signed informed consent form d()I:~; not guarantee "informed choice:' Insome instances, a client might sign without understanding the information provided, or aclient may "consent" to a method or procedure without l'eeling that he or she has any choice inthe matter. In addition, informed consent is meant to protect the client's right to make a voluntary and informed decision, but some providers use il primarily to protect themselves or theinstitution against subsequent accusations of coercion from clients,

lnformed choice: The concept of "informed choice-, means that, with or without a signeddocument, the client should be making a voluntary and well-informed decision. This termoriginally was associated with family planning, wherein an individual freely chooses whetherto use a contraceptive, and which one, Although in formed choice can apply to any SRHservice, some providers have difficulty understanding '"informed choice" outside of familyplanning services, because only one treatment option may exist (e.g., there is only one medication for syphilis, ancl thus no "choice") or becaus<~ the individual's medical conditionrequires the provider to make emergency decisions for the (usually female) client (e.g., inpostabortion care or emergency obstetric care).

Informed and voluntary decision making: This is baSically the same as "informed choice,"but we use this term to underscore the importance of the: decisions that individuals do make inevery area of reproductive and sexual health-even when options are limited and the need isurgent.


Appendix C

Slide 8

Why Informed and VoluntaryDecision Making

for Reproductive Health?

• Medical ethicSif1Uman rights

• Policy requirements

• Quality of care client satisfaction

• Program benefits confirmed by research

• Practical benefit to clients

Slide 9

Informed and VoluntaryDecision Making

Is a Good Program Strategy

Research tell us that informed choice leads to:

• Belter method use and client compliance withtreatment regimens

• Continued method use

• Satisfied clients, who In turn are good programpromoters

Notes to Slide 8:

We have talked about the human right:' th:Hunderpin informed and voluntary deci:'lonmaking. Sometimes ensuring client .... mfom1eJchoice is explicitly required in service gUIdelines and policies.

Informed and \'oluntary decision making is recognized as an essential element of good-quali[~

services. which increase client sJtisfactionHelping clients make informed and \'o[untaf\decisions about their reproJuctl\'e health al ... ~)has practical benefits [0 program:-- J.oJ te'clients. which we will talk ahoul in lhe !le\t

few slide.'"

Notes to Slide 9:

Better method use and client C(lmrJi:!r1Cl' k;dto a reduction in unintended pregnJ.ncle~ ~tnJ [(I

improved health.

Continued method usc results from cIiem,,' ~el

ling the method they want and being prep,;edfor side effech.

EngenderHealth ComprehenSive Counseling tor ReprOductive Health-Tramers '.lanua 221

Appendix C

Slide 10

Research Also Tells Us That...

Giving people a choice of family planning makes a

difference.

• Contraceptive use is highest when a variety of

contraceptive choices are readily available (Ross et

al,. 20021

• When people get tile method they prefer, they are

more likely to continue using it IParia"" 1991)

• Increased continuation contributes more to

contraceptive prevalence rates than an increase

in new users (Jain, 1883)

Slide 11

More evidence from research ...

One of the major reasons why clients discontinue

pills and injectables is that they are not adequately

informed about side effects.

SoIiR'Il'.-Et'lgendEtrH&alth :>Iudi~s in Cambodia (2DOO).']n::! Nepal (2'OO~)

Notes to Slide 10:

The full sources supporting these points are as

follows:

"Contraceptive use is highest when a variety of

contraceptive choices are readily available"~Ross,

J., et al. 2002. Contraceptive method choice in devel

oping countries. International Family Planning

Perspectives 28( 1):32-40.

"When people get the method they prefer, they

are more likely to continue using it"~Pariani, S.,

Heer, D. M, and Van Arsdol, M. D. 1991. Does

choice make a difference to contraceptive use?

Evidence from East Java. Studies in Family Planning

22(6):384·390.

"Increased continuation contributes more to contra

ceptive prc1valence rates than an increase in new

users"---.Iain, A. K. 1989. Fertility reduction and the

quality of family planning services. Studies in

Family Planning 20(1): J-16.

Notes to Slide 11:

Informing clients about what to expect and

about what is nonnal reduces fear and dissatis

faction, and eases adjustment to proper method

use and client satisfaction.

222 Comprehensive Counseling for Reproductive Health-Trainers' Manuai EngenderHealth

Appendix C

Slide 12

Notes to Slide 12:

Consequences of Not EnsuringInformed Choice

in Family Planning

• Improper method use. resultmg in unintendedpregnancy

• Fear of and dlssatisfachon wIth side eHects.leading to discontinuation

• Failure to recognize serious warning signs.leading to health risks

• Dissatisfaction with quality of interaction orwith method given. leading to drop-ou!. poorword cf mouth and low use of serVices

Slide 13

And Yet. ..The Reality of Informed andVoluntary Decision Making

in Practice

Individuals ability to exercise their rights to makeinformed and voluntary family planning andreproductive health deciSions is hindered by

• Social and cultural factors

• Laws and poliCies

• Service-delivery practices

• Providers attitudes

• Resource constraints

The consequences of m('thod failure or di-continuation often are unintended pregnancy. anJas a result client di"sall"factlOn with the program. This in turn can lead to low kwh (Ifservice utilization and of contraceptive prC\alence _

Extreme cases in which provlder" make decisions for clients and do not tell them that aprocedure ha" he-en performed I e.f .. postpartum ILD ins('f[ ion ()r sten lizat Ion p('rfl)rtnedwithout informed ChOiCC [)[ COllscnt, canc1eqroy the credihility of enure prns-ram-.;

Notes to Slide 13:

Some of the chalknt:c-..:

• Rcproductiw rights and informed clwicc arcstill new concepts in ,orne culture:' and pr(lgrams.

• Some donor:--.. go\·ernmellts. and family planning programs "ct goab for "en Ice performance and resulb. which may he rcrcci\...~das "targets" hy pwgram 1l1:1n~1~eh (Ir -eI\j.:cproYidcrs. Thi, may Cfl'atc a sy~tematl.: ~las

for or agall1st particular methods. \\hh.:h ,:~Ln

compromise cIicnh' free choice.

• Some program planners still consider COUllseling a luxury for \\hlch they do not hah~

sufficient resources. ComlOcing them thatcounseling is a kc;. to scnice quality. ellentsatisfaction. and achie\emenr of programgoals can be challengmg.

EngenderHeal1h Comprehensive Counseling for Reproducllve Health-Tramers' Manual 223

Appendix C

Slide 14

Research and ObservationTell Us:

Counseling often does not meet clients' informationaland emotional needs

• Incomplete information or information overload

• Little or no preparation for side effects

• Failure to address fears and concerns

Many providers lack

• Good communication skills

• A client-centered approach

• The knowledge that they need for effectivecounseling

• Comfort in discussing SRH

• Adequate management and supervisory support

Slide 15

An Expanded ConceptualFramework

Basic elements that support informed andvoluntary SRH decision making:


2. The decision~makingprocess is voluntary.


4. Good client-provider interaction, inclUdingcounseling, is ensured.

5. The social and rights context supportsautonomous decision making.

Source: EngliltJdelHeaRh. 2003. CrJOicl?$ .'" family nl;mr.'ng. In.Ic,m~ .'l!1d vo.'Llnroiry decisionmaki/l9_ NilW .....or\c

Notes to Slide 14:

• Providers do not assess what the client needsand wants and do not tailor the interactionand information to the individual; they tendto give standard information whether theclient needs it or not.

• Providers often fail to elicit informationaboLlt the client's medical and contraceptivehistory.

• Most family planning providers fail to assessthe client's risk of HIV and AIDS and to discuss the protection that different methodsoffer.

• Many providers have a poor attitude towardclient" and treat them without kindness andrespect.

• Some providers deliberately tell clients onlypositive information, believing that if theydescnbe side effects, risks, and discomforts,they will scare clients away.

Notes to Slide 15:

EngenderHealth (formerly AVSC International)developed an expanded framework for informedand voluntary decision making, to offer practicalguidance to service providers and program planners. This framework identifies five basic elements that support informed and voluntary decision making; a recently developed "tool kit"guides program managers, decision makers,service providers, and community leaders inassessing factors within each element that support or h:lTIder informed choice in their settings,and developing action plans.

For each element, the framework suggests indicators thaI one can look for to assess whetherthese elements are in place. The following areexamples of indicators:


• Services are available where and whenpeople need them.


Appendix C

• A choice of services is offered.

• Linkages exist with other health sen'ice". and referral mechanism" arc In plJ.ce.2. The decision-making process is voluntary,

• People are free to decide whether to use sen·ices. without coercIOn or constraint.

• People are free to choose among availahle service options. witham coercion or con'traint

• A range of service options is accessible to all categories of clients. including unmarriedindividuals and adolescents.

• Service providers are objective regarding all clients and all services.

• Individuals' right to choose is respected ancl supported.


• People have access to appropriate and accurate information about :-.enices ancl orti~ln:-..

• People understand their risk of STh and HIV or AIDS and the protection prOVided by dIf-ferent family planning method options.

• Servicc providers assess client:-;' knowkdge, fill in gaps. and L'orred an:- mi"inf~)rJnJti~ln.

• Comprehensible posters and tlipcharts are clearly in clients' view.

• Samples of family planning mcthods arc 3\ailablc for clients to "ce ~md touch.• Clients understand their options. essential information about their cho:-.en method ~)r trc.lt

ment. and ho\\' it may affect their pCTs('nal :-.ituatinn.

4, Good client-provider interaction. lIlcludll1g coun.'eling. is a:-.:-.Llrcd.

• Clients actively participate in discusslons and are encouraged to a"k: que:-.tinn'

• All staff have good communication skills.

• All staff use bnguage and terms clients can understand.

• All staff have complete and correct infonnation annut SRH and aval1abk :-.ef\ICe<..

• All staff are respectful. nonjudgmental. and scnsiti\c to power imhalances.

• All staff maintain clients' privacy and confiuentiality,

• Trained staff are assigned to counsel clients as a routine component of sen ice..;

• Counseling serves as the checkpoint to ensure voluntary and infol11lCd deciSIOn maKmg.

• The service setting is organized. c1e~m. and cheerful. to put client" at ease.• Auditory and visual pri\'acy ,U'C assureu for COUIN:~ling. regarJk"" pf [!lc,cwng.

• Adequate seating is a\'ailablc during coun"ding for staff. client". and ,1l1V~lne ci,e theclients choose.

5. The social and rights context supports autonomous decision making.

• Laws, policies, and social norms support the following. plus other related nghts::» Gender equity

>- Individuals' right to decide whether and when to have children. and how man\

>- Clients' right to access SRH infol111ation and sen·ices. regardless of age. gender. maritalstatus, or sexual orientation

>- The right to make decision" conccming SRH free of discrimmation. coercion. andviolence

(Note: This framework applies [0 [he full array \1f SRH sen Ices. a, well .I:' f,llllih r!..lnnln~. II ]0. :hJJricJ fh'mEngcndcrHcalth. 2003. Choias il/fami" planning: blj!I/'lIiU} and lolUlltlin dfClSioli nllikill~'. :\c\\ Yc·rk.'

EngenderHealth Comprehensive Counseling for Reproductive Heafth-Tra!ne~s' \-~a'lual 225

Appendix C

Slide 16

Influences AffectingInformed and VoluntaryDecision Making in SRH

Individualand

community

Notes to Slide 16:

Decision making about SRH is complex andindividualized, and is often influenced byan interplay of factors related to: individualcircumstances; the legal, social, and rightscontext in which an individual lives; policiesaffecting information and services; and service-del ivery practices.

/Policy .........----i..~ Service

delivery

Consideri ng the complexity of the individual'sdecision~ rnaking process regarding SRH andthe factors beyond service delivery that influence the quality of SRH care provided, anaccurate and complete understanding ofinformed and voluntary decision making canonly be acbieved when all of these factors~

communi Ly, policy, and service delivery~are

considered, both in themselves and in terms ofhmv they i;lfluence eacb other.

The next three slides give examples of factorsin each area.


Appendix C

Slide 17

Individual and CommunityFactors...


• Sociocultural expectations and beliefs

• Rights context and individual status

• Sources and quality of information

~ Family and fnends

~ Public tnformation and educalion:

media campaigns. articles. and

radio or TV broadcasts

~ Outreach workers

Notes to Slide 17:

Indh'idual and communit~· factors Include- all

of the family. educational. rehg10u:,. and "'(~Ial

messages that people experience as they grc.\\ up

and live in a particular communIty. plu:, the

unique way in which the indIvidual procc:,ses

and interprets all of the.;e factor.;. On the one

hand. an indi\'idual's sense of what he or .;he

needs and wants in term, of hi ... or her own SRH

is a "ery personal expenencc. yet on the other

hand it is very heJsily intlue-nced ~y community

expectations of whal i ... rIght or \\TOno;. g~,oJ \Jr

bad, and acceptable or unJ.ccepta~k.

These influences are partIcularly poweriul In

determining what people fed that they I.."an l'f

cannot talk about. and with whom. Such communication orrortunitie ... and '::tln:--t~all1:... ~trc ky

to the "informed" element of informed choice. The community Jho play, a ro\~crilll rok in

determining who is expected lor allowed) to make dcci~i('n, ahnut SRH ~mJ '.\ h:li kinJ, \,f

choices are acceptable.

SRH decision making is a compkx process t.hat starts heJ;m- the clicnt L'l)l11c' t~) the Cllllll:. The

first decision is \vhether to seek sen'ices: many potential client'> choose not to d~):--o Sl'Dw;,.'k

ments of this aspect of the deci:-.ion-making proce" ... include.

• The client's ability or inability to make independent decisions (i.e .. who holds ro\\cr ll1 the

family?)

• Personal attitudes and preferences

• Knowledge or misinfonnation (from such sources as other satISfied or uns~lti,ficd dient ... :

paid or volunteer outreach workers: information. education. and communication campaigns:

and common rumors or misconceptions)

A variety of cultural and community factors influence c\iCIH..," Je":l ... WI1 IlMkin~ ,It'c1ut ~dl

aspects of their lives. The following are just a few examples:

• Social and culll/ral background. This includes such factors as rdigiou'> belief... aholll contra

ception. a preference for sons. a perception that a large family sigmfic:-. wealth or sene.; J:'

insurance for old age. and a woman's value bemg seen chieny In term.s (If her fertility.

~larginalized groups, including poor. uneducated women and youth. often lack acees, to

choices and have limited ability to make autonomous deCISions.

• Rights context. This may involve the right to decide when to have children and how many to

have. the right to be treated with respect and dignity. the nght to a range of famIly planning

methods. the right to complete and comprehensible infoffi1ation. and the right to infonl1ation

and services related to HIV, AIDS. STls. and other health condition". The c1ienl\ indiyidual

status (in terms of socioeconomic status. age, gender. marital statu,>. edu..:ationa.l attainment.

or sexual orientation) influences his or her awarene..;" of and ahility to :.b,-crt the,>e nght".

• Sources and quality ofinfomwtion. In all cultures. family and friend" are a primary source of

infonnation about SRR Others include public media and outreach efforts ~y health work.ers.

EngenderHealth Comprehensive Counseling for Reproductive Health-Trainers· Manual 227

• Method and service options available on-site• Fee structure for SRH services

Service-Site Factors...That Affect Decision Making

• Providers' attitudes, knowledge, and skills in SRH• Quality of counseling and time allocated for it• Client education matenals

Appendix C

Slide 18

Notes to Slide 18:

Service"sih~ factors can be viewed from at leastthree perspectives-the client's, the provider's,and the supervisor's. All three perspectives needto be considered when the impact of servicedelivery practices on informed and voluntarydecision making is being assessed. This includeswhat services are actually provided, by whomthey are provided, and the quality of care that isoffered, as perceived by the client. The level andnature of training for providers needs to be considered, because it is unfair to expect providersto offer services in a manner for which they havenot been trained. The role (and training) ofsupervisors is also important, because it is difficult for providers to make changes if they do notreceive institutional support and ongoing guidance for those changes. Remember also thatproviders and supervisors arc just as much influenced by the norms of their home communityas clients are.

Some clients make a firm choice before coming to the clinic, although that choice mayor maynot be voluntary and well-informed. Others come to the clinic to seck help from a health professional, to learn about and be able to choose among method or service options. Regardlessof external factors, clinic staff should serve as the checkpoint to determining where the clientis in the decision-making process and then should meet that client's individual needs, eitherconfirming that informed and voluntary decision making has been made or helping the clientto make the decision. In the reality of program implementatIOn and day-to-day service delivery, there are additional challenges to informed and voluntary decision making.

Specifically, the provider's role in ensuring informed and voluntary decision making is to:• Give clients rcal options and correct information (assessmg what they already know and

want, filling the gaps to meet their needs, and correcting rni sinformation)• Help clients exercise their right to decide• Help clients confirm or reach appropriate decisions (i.e., choose services that are reasonable

for their circumstances, lifestyle, and health status, and make sure that they do not haveunrealistic expectations)

Note: You may want to prepare a flipchart showing these three points, to keep posted throughout the training.


Appendix C

Slide 19

Notes to Slide 19:

Policy and Program Factors...


• Policies concerning an individual'sright to access SRH services.regardless of age or marital status

• Laws concernmg an mdlvldual'sdecision-making rights wilt1 respectto SRH care

• Integration of SRH services

• Targets. quotas. or performance-basedfunding m family plannmg services

• Per-case referral or provider paymentsin family planning services

Policy and program factors L In compromiseclients' options. their access to ll1fom1..lt10n or s<:rvices, and their ability to deCIde for themselws.

Policies can include law". gO\'ernmental goals.programming objecliws. and SCf\lcc-deliwr:guidelines. Factors that influencc policlcsinclude politics. economics. demographic pre:.sures. religion. and cultural expectati~)ns. \\lthmedicine and public health playmg an ImporUnthut often limited wle. Po1Jcic-. Me meant (()guide program manager:' and :-cr\"1(C rro\l ...kr,in terms of their scope of work and the quality ofcare expected of them. Howcver. many polJcle:-'actual meaning and intent are llL't adequatelycommunicated to the people \\I1l) arc mcant tobe guided by them.

:'-late: Laws and policies regarding access to services and thc right to make onc':- O\\ll d;?Chlt'n:may be positive or negative. For example. targets and quotas. performance-h~b;?J funding t,rreporting. and payments to providers or clients are generally considered to he potentiai thre~ih

to informed choice in family planning.

The Tiahrt Amendmellt (1998)One example of a policy factor that affects infom1ed choice in family planning IS the TiahrtAmendment. an amendment to an appropriations bill passed hy the l-S Congre~~ In 1998.Thjs amendment specifically addressed is<;ues of informed choice and \oluntarisrn trl familyplanning service-delivery projects supported by the l'.S. Agency for International [xvdopmcrH(USAID). Actually. most countries in which USAID supports family pl:mning pfClgrams ha\·cmuch broader guidelines concerning quality of carc. informcd choice. ~tnd \l,lu!1t,lri,m than theTiahrt Amendment requires. The difference is that the Tiabrt :\mcnJment I' ~1ll ;!du~d 1.1\\-

rather than a guideline-requiring that LSAID report any violations to the l-.S C ~'1n~rc~s

The Tiahrt Amendment identifies ti\·c specific requirements for t:S ...'dD-a""SI.;.ted famllv planning projects:

• Targets or quotas must not he used.

• Incentiws and financial awards may not he used to reward client;,; for accepting a famIlyplanning method or 10 re\vard program personnel for recruiting family planning client,....

• Benefits or rights must not be tied to the acceptance of a family planning method

• Clients must receive comprehensible infoTInation on health benefit" and nsb. ina.:h·is3bleconditions (e.g., conditions under which a method should not be u:--ed I. 3nd 3d\er"e SIdeeffects associated with the family planning method selected.

• Experimental contraceptive methods must be provided in tht: context of J :--cit=ntltlc .;.(udy In

which participants are advised of their potential risks and benefits.

EngenderHealth ComprehenSive Counseling for Reproducllve Heaith-Trainers' Manual 229

• Help service providers to consider and addressclient issues that extend beyond the clinic

• Join or create alliances to advocate for social andpolicy change

• Ensure access to service options

• Increase individual and community participation

Applying the ExpandedFramework:

Fostering a Supportive Social, Policy,and Service-Delivery Environment

for Informed and VoluntaryDecision Making

Appendix C

Slide 20Notes to Slide 20:

Looking at the impact and interaction of allthree areas of influence on informed choicepolicy, service delivery, and community-mayfoster a supportive rights and policy environment for informed choice, one that encourageshealthy client decision making. Specific strategies include:

• Embracing an expanded framework ofinformed choice that extends beyond theclinic walls to incorporate broader socialaspects of decision making and access toservices, and recognizing the impact of cultural factors on couple-provider interactionand on clients' ability to make autonomousdecisions

• Forging alliances and creating or joining multisectoral coalitions to advocate for social andpolicy change to support, promote, and protect cI ients' rights and informed choice

• Ensuring access to service options• Increasing client and community participation in public information efforts, program

design, and program evaluation, to better understand and meet client needs and to makeprograms more accountable to the community they serve

SJide21

The Value of Informed andVoluntary Decision Making

Supporting clients' informed and voluntarydecision making:

• Helps people exercise their right to makeand act on their own decisions about theirhealth and reproduction

• Helps meet clients' needs and increaseclients'satisfaction

• Helps meet programmatic goals

Notes to Slide 21:

• There is a moral imperative to ensuring thatclients make informed and voluntary decisiam; based on their recognized rights. (It isthe right dung to do.)

• Ensuring informed and voluntary client decisions maintains or improves quality of care,which increases client satisfaction.

• Ensuring mformed and voluntary client decisions meets program goals as a result ofincreased method adoption, improvedmethod and medication use, improved compliance w'ith treatment regimens, andincreased continuity of care.


EngenderH ealth

Appendix 0Participants' Self-Assessment of

Knowledge and Attitudes: Pretest/Posttest

Comprehensive Counseling for Reproductive Healtrr---Tralners' Manual 231

Appendix 0r----------------------------------- ,--~

Participants' Self-Assessment of Knowledge and Attitudes:Pretest/Posttest

Name (or number): _ Date: _

5.

4.

7.

6.

3.

Decide whether each of the follml'ing statements is T (true) or F (false!. H'rire yOUT n'S!'(lf/Se

for each statement ill the\pace pm\'ided,

1. In integrated SRH counseling. the purpose of listening to clients is to allt1\\ ;he ~('r

vice provider to obtain enough information from the client to he ahle tn JCL'lcic ht)\\

to tailor the discussion and the information presented.

In integrated SRH counseling. closed-ended qucsti0ns Jrc more effecti\';? f()~ m·~;?t

ing clients' needs than open-ended qucstions. hecause they altow the ~e[\h:e

provider to see morc clients in less time.

In integrated SRH counseling. heing able to reflect on the pros and L-l'n~ of ~:ll alternatives enables clients to find their own solutions to their problems.

A principal purpose of integrated SRH counseling is to hclp "en ice pr()\ldcr" .l'~!'t

clients to take responsibility for making and implementing de(]'lOn~ -:'.%:efmn:,:

their problems.

In integrated SRH counseling. it is not appropriate for "ernce pronder, 1,1 ,h.lretheir personal reactions to their clients' "c:\ual hehavior.

In integrated SRH counseling. service pnwiders should alwa\:-- u"e cllnil..,d terTI!nology with clients. to cnable clients to improvc their knowlcdf:e.

The same sexual behavior rna)' he risky in one situation and not in anl)ther.

The follml'i1!g are nlulriple-cJwice questions. Please circle tht' correct response fl'" (,Jellquestion. Unless otherwise indicated. there is of/ly Of/e correct rCI/umsefi)f' t'uch (!i/CST/Ill!

8. \VhlCh of [he follO\ving i:- nor a re"ponsihilit'y of senice prmlder:- Il1 c,)un,cltn~ ~ \".111;::

people'?

a. Be a reliable. factual source of information about SRH

b. Create an atmosphere of privacy. respect. and trust

c. Advise the client about the morality of his or her behavior

d, Engage in a dialogue or an open discussion with the client

9. Which of the following is fwr required for a client to bc ahle to make an lIlfl)rmedchoice?

a. Service provider's recommendation

b. Availability of appropriate information

c. Voluntary decision-making process

d. Availability of adequate service options

EngenderHeallh Comprehensive Counseling for Reproductive Heallh-Trainers Manual 233

;·r:~\lIOUS P~GE BLA~JK

Appendix DSelf-Assessment-_.~-- ----------------------------,

-----------------~--------

10-13. Which of the following indicates that a service provider is etfectively listening to aclient? (There are four correct responses.)

a. Occasionally paraphrasing or summarizing VI/hat the client has said

b. Looking at the client when he or she is talking

c. Thinking about what you will say next to the client

d. Writing or reading notes when the client is speaking

e. Asking speci11c questions related to what the client has told you

f. Interrupting the client to give him or her advice

g. Nodding your head or making encouraging sounds when the client is talking

Please answer the following questions in the space prmided.

Define the terms:

14. Informed choice

15. Informed consent

Namefive client rights that apply to the provision ofSRH services.

16.

17.

18.

19.

20.

Name five types ofhealth services that are considered to he the components of SRH care.

21.

22.

23.

24.

25.___________________________________________--1


Appendix 0!Self-Assessment~----------~~--~-- _

Name fOllr categories of behavior that people lise to control their parmer.l· Ifl H'XIWI

relationships.

26.

27.

28.

, 29.

lvlatch the temlS with their definitiollS, hy placing the nllmber (d the deflnirioll in .iron! of tIlt'ten71 to u'hich it applies.

Gender

Gender role

30. Socially and culturally defined attitudes. behu\loh. cxpeetation~, and rcsponslhilitiC':-- (L~r

males and females

31. How an individual or society defmes "female" or "male"

The follOll'illg are examples (~f qllestions rhat [/ prm'ider mig/If (lsk in rhe cmlteXl (~f ,1l1

SRH con.wltation. Ret'ieH' the qllestions he/ml', ulld \\rire C (lor closed-ended lund 0 IJr1r

open-ended), as appropriate, ill the space prm'ided

~2. __ Do you remember what to c!0 if Y0U mi.;s nne rilP

33. HO\v old arc you'J

34. How do you feel now?

35. When did the bleeding start'?

36. __ How \I,!ould you feel about using: Ihe pill}

37. Is your home far from this c1iniL"1

38. __~ How did you feel when you tirst found (lUI you were pregnant'

39. __ What do you plan Eo do to protect yourself from getting pregnant again'.'

40. Ho\v \vould you feel ahout nol having any more children':

41. __ How many children do you ha\'t~')

42. What questions or concerns does your husband or partner have about your

condition?

43. Do you realize that a tubal sterilization is permanent'l

44, What do you know aboul HIV and STI,,')

45. Do you have any idea if your partner has other sexual partners')

EngenderHealth Comprehensive Counseling for Reproductive Healt~Trainers' Manual 235

Appendix 0Self-Assessment-~~~-~~~---

ForREDI:

In SRH counseling, the acronym "RED/" refers to certain steps in counseling. What is thestep represented hy each of these letters?

46. R: __~ _

47. E: __~ ~ ~_

48. D: ~ _

49. I : _

Review the activities belm'!.', and write the letter for the activity, as appropriate, in the spaceprovided next to the corresponding step ofRED!.

50. R: _

51. E: _

52. D: _

53. 1: _

Activities:

a. Help the client consider how his or her fami Iy might react to his or her choice ofactions.

b. Offer ideas for improving communication and negotiation with the client's partner.

c. Ask about the client's relationships and behaviors that might put him or her at riskfor an unintended pregnancy or a sexually transmitted infection.

d. Assure the client of confidentiality.

ForGATHER:

In counseling, the acronym "GATHER" refers to certain steps in counseling. What step isrepresented by each of the letters?

46. G: _

47. A: ._. ~

48. T: _

49. H: ~

50. E: ._.~ _

51. R: _

'-- ~__.~~ ___J


Appendix 0Self-Assessment-~----------_-__~ ~__~_~ _

IRe>iew the aClivilies belOH; alld ,rcite the letter foc Ihe arti,itl'. OJ appmpc", 'e. m rhe Sp,I"'·I~rovided next to the corresponding step of GATHER.152. G:! 53. A:---

i 54. T: ----55. H: _

56. E: __~

57. R: __~

Acti"ities:a. Assist the client to identify his or her options and the PfClS and con" l'1' ;?:lchb. Ask the client to repeat the instructions. Listen carefully to make sure that he Clf

she remembers and understands important information.c. Briefly describe the prevention and treatment measures in which the .:lIent j,

interested.d. Explain what will happen during the ,·isir.e. Ask the client what he or she knows about the prevention or trcatment me:bures

that are of in terest.f. Invite the client to come back at any time for any rcason.

EngenderHealth Comprehensive Counseling for ReprOductive Health-TraIners Manual 237

Appendix 0

Answers to:

Participants' Self-Assessment of Knowledge and Attitudes:PretesUPosttest

! Decide whether each of the follmrillg statements is T I true J or F Ifalse J. Write your responseI for each statement in the space prodded.

1.~ In integrated SRH counseling. the purpose of listening to client-. i~ to allo\\ the ~er

\'ice provider to obtain enough information from the client to he ~lhlc to JeciJc h\1\\

to tailor the discussion and the informatIOn presented.

2.~ In integrated SRH counseling. clo~t:d-cnJcJ quc~tilm" arc morl.' effectivc fl)r I1lCl.'ting client's needs than open-ended questions, hecause they allo\\" the scniceprovider to see more clients in less time.

3 --.I_ In integrated SRH counseling. being ahle to reflect on the pro.s and can:' of all alternatives enables clients to find their o\\"n solutions to their problems.

4.~ ....... principal purpose of integrated SRH counseling is to help sen'ice prmidcrs ;lssiqclients to take responsihility for making and irnpkmenti0S" decision" concern in::their problems.

5. ----L In integrated SRH cotlnsehng, it is not appropriate for senice providers to sharetheir personal reactions to their clIents' sexual heha\·ior.

6.~ In integrated SRH counseling. service rro\'idcrs should a]w,ly" U."'(' clinical lermi

nology with clients, to enable cltt'nrs to improve their kno\\kJge.

7. -L The same sexual beh~l\"ior may be risk~' in one SItuation and not in another.

The fallml'i1/g are multiple-choict.' (Illcstiolls. Pleasc circle The correct response .fll" Cillh

question Unless othenrise indicated. there is only 01/1.' correct respo1/sefoJ" each (iliest/o,!

8. Which of the following is nol LI re~poosihiJity of ~l.'f\·icc prlH·luer..; III l."oun ...elin; ~ ,),li1~

people?

a. Be a reliable. factual source of information ahout SRH

b. Create an atmosphere of privacy. respect. and lfLl'it

o Advise the client about the morality of hi" or her behavior

d. Engage in a dialogue or an open discussion with the client

9. Which of the follo\ving is not required for a client to be able to make an mformed

choice?o Service provider's recommendation

b. Availability of appropriate infonnation

c. Voluntary decision-making process

d. Availability of adequate service options

EngenderHeallh Comprehensive Counseling for Reproduchve Heallh~Trainers Manual 239

PF;[VIOUS PAGE BLANK

Appendix 0Self-Assessment: Answers ------~-._--_._ -.-------------__,

10-13. Which of the following indicates that a service provider is effectively listening to aclient? (There are four correct responses.)o Occasionally paraphrasing or summarizing 'VI hat the client has said

® Looking at the client when he or she is talkmg

c. Thinking about what you will say next to the client

d. Writing or reading notes when the client is speaking

® Asking specific questions related to what the client has told you

f. Interrupting the client to give him or her advice

® Nodding your head or making encouraging sounds when the client is talking

Please answer the jolfo>ving questions in the space provided.

Define the terms:

14. Informed choice

Correct answers should have at least three of the .Following elements, although exactlythe same wording is not required:

Informed choice is an individual's well-considered, voluntary decision based onoptions, information, and understanding.

1S. Informed consent

Correct answers should have at least three of the following elements, although exactlythe same wording is not required:

Informed consent is a medical, legal, and ri~hts-hasedconstruct whereby the clientagrees to receive medical treatment, to use a family planning method, or to takepart in a study, (ideally) as a result of his or her informed choice.

16-20. Name five client rights that apply to the provision of SRH services.

Any five of the j{)llowing are correct, although exactly the same wording is notrequired:

Information

Access to services

Informed choice

Safety of services

Privacy and confidentiality (can be listed separately)

Dignity, comfort, and expression of opinion (can be listed separately)

Continuity of care


Appendix 0Self-Assessment: Answers ----------------~-----~

21-25. Name five types of health services that are considered to be the componenr- t)1 SRHcare.

Any fi\'e of the following are corrt!cr. although exactl" the same 1\"0,.£11" I? is notrequired:

Family planning information, counseling. and ser\"ices

Prevention and treatment of STIs and RTIs

Diagnosis and treatment of HIV and AIDS

Antenatal. postpartum, and delivery care

Health care for infants

Management of abortion-related complications

Prewntion and treatment of infertilit~

Information. education. and counseling on human sexuality. SRH.and parenthood

Diagnosis and treatment of cancers of the reproduetin system

Sallie j()I{/" categories [~f bell(H"ior [hLit pcople lise I,) control [hell ;',il:n(}", ", \, '.:L:.'

relationships.

26. Ph\"sical

27. EmotionalJPsychological

28. Financial

29. Sexual

lv/atch the terms with their definitions. by placing the /lumher (~f tile tier/flit/on in t/"lifl; ot thetenn to H'hieh it applies,

31 Gender

30 Gender role

30. Socially and culturally defined attitudes. ~haviors. expectations. and rcspc)n,ibtll!J\?" INmales and females

31. How an individual or societv defines "female" or "male"

The follmring are examples of questio1/S that a prm'ider might ask in the COl/telt of lin SRHc01l5llltarion. Review the qllestions heloh', (ll/d lI.,ite C ({or closed-ended I (Ind 0 Ifor openended), as appropriate. in the space prm:ided.

32.~ Do you remember \vhat to do if you miss one pill'?

33.~ How old are you?

34,~ How do you feel now')

EngenderHealth ComprehenSive Counseling for Reproductive Health~Trainers Manual 241

Appendix 0Self-Assessment: Answers ---~~----.-

35.~ When did the bleeding start?

36.~ How would you feel about using the pill'~

37.~ Is your home far from this clinic?

38.~ How did you feel when you first found out you were pregnant?

39.~ What do you plan to do to protect yourself from getting pregnant again?

40. ---.!l- How would you fecI about not having anymore children?

41.~ How many children do you have?

42. ---.!l- What questions or concerns does your husband or partner have about yourcondition?

43.~ Do you realize that a tubectomy is permanent?

44. ---.!l- What do you know about HIV and 5TIs')

45.~ Do you have any idea if your partner has OI:ber sexual partners?

ForREDI:

In SRH counseling, the acronym "RED/" refers to certain steps in counseling. What is thestep represented by each of these letters?

46. R: _-----"R~a"-Jp~p"-'o"-"r~t~-b~u""'il"'d!..!.!in!..!.lg ~_

47. E: _------'E=x~PI""I"-"o'-"-r=a=ti=o=n----------

48. D: __~D~e,-"c""is""i"""o"-,n~m"-=a,,,k,,,in....gD-- _

49. I : _-----'I=m=p~l=e""m=e=n=t=in:.:.o2...._=th=e"-d=e=c=i=si""o=n'----------

Review the activities below, and write the letter for the activity, as appropriate, in the spaceprovided alongside (~f the corresponding step ofRED/.

50. R: d

51. E: c

52. D: a

53. I: b

Activities:

a. Help the client consider how his or her family might react to his or her choice ofactions.

b. Offer ideas for improving communication and negotiation with the client's partner.

c. Ask about the client's relationships and behaviors that might put him or her at riskfor an unintended pregnancy or a sexually transmitted infection.

d. Assure the client of confidentiality.


Appendix 0,Self-Assessment: Answers ~-~---------~-~ ~

ForGATHER:

In counseling. the acronym "GA.THER" ref(:rs to certain steps 111 counselin,!. \r!Wf Sft'!' ISrepresented by each of the letters?

46. G: Greet

47. A: Ask/Assess

48. T: Tell

49. H: Help

50. E: Explain

51. R: Return visitlReferral

Rel'iew rhe activities bdoll'. and \ITire the letter for the aCf/\'ir\', liS appropricift'. in rhe SPUct'prodded next to the corresponding .srep (~l G.·\THER.

52. G: d

53. A: e

54. T: c

55, H: a

56. E: b

57. R: _f_

Activities:

a. Assist the client to identify his or her options and the pros and con-. of each,b. Ask the client to repeat the instmc[ions. Listen carefully [0 make sure that he 1'[

she remembers and understands imp0I13l1t informati011.c. Briefly describe the pre\'ention and treatment measures in whJCh the client I"

interested.d. Explain what will happen during the \·isit.e. Ask the client \vhat he or she knows about the prevention or treatment me~bure"

that are of interest.f. Invite the client to come back. at any lime for any reason,

EngenderHealth Comprehensive Counseling for Reproductive Heallh-Tramers ManLial 243

EngenderHeafth

Appendix EParticipant Evaluation Form

Comprehensive Counseling tor Reproductive Heajth~Tra:ners' ,','an:.13 ! 245

FREVIOUS P,~GE BLANK

Appendix E

Participant Evaluation Form

Please answer all sections of this evaluation fonn, using the reverse "ide for comment~. Ifneeded. Your responses will assist the training organizers in determining wh:1t modiflcJtll1lb.if any, should be made to this program.

I. Overall EvaluationPlease check the choice that best reflects your overall cy.:duation of this training:

:J Very good [) Good :.J Fair :J Poor

II. Achievement of ObjectivesThe general objectives of the training arc to cnsure th:lt you ha\t:~ the kn{1wledgc. atutuJc'.and skills necessary to carry out the key tasks of mtegratcc! sexual and rcpWdUCli\c he.dth(SRH) counseling. For each task (below l. please circle the appropriate numhcr 111 lnLIJ,:atcthe degree to which you feel thJt objective \\:1:-. achlc\'cd: :) :::: lOtall~ a":-1l1c\'ed: -+ :::: rn,'~ti~achieved: 3:::: somewhat achieved: :2 :::: hardly achievcd: and I :::: not at all aChIC\ed.

For any objectives given a rating of I. 2. or 3. plea-;c indicate 111 the Commenb/Suggt>Ut1n,column \\-hy you feel that it was somewhat. hardly. ('Ir not at all ~Ichi('ycd ~lT1d rlc:!'l' nflU .E'~suggestions you might have to improve it.

EngenderH ealth Comprehensive Counseling for Reproductrve Heal:r,-Trainers Manua' 247

h:'EViOUS PAGE BLANK

Appendix EParticipant Evaluation Form

III. Other Aspects of the Training

For each of the following questions, check the response that best represents your opinion.

Please add any other comments you have.

1. How relevant to your work was the overall workshop?

o Extremely 0 Mostly 0 Somewhat [.I Not very 0 Not at all

• What aspects of the workshop were the most imponam or useful for you? Why?

------------------_.__ .--~.

• What aspects of the workshop were the least important or lIseful for you? Why?

• Additional comments:

2. How well did the course content meet your expectations?

o Totally

• Comments:

o Mostly o Partially o !~ot at all

----------------~._-_.

_ .._------------

.__._._------------

3. How well did the training methods contribute to achieving the workshop objectives?

o Extremely well 0 Mostly

• Comments:

o Moderately o Minimally o Not at all


Appendix E! Participant Evaluation Form-------------------- _

3. How well did the training methods used contribute to achie\ing the worbhor obJect!\e<)(continued)

• The most effective training methods were:

• The least effective training methods were:

4. How well did the materials distributed in the \\orksbop contrihutc to your learnli1g'

o Extremely well [) Ylostlv :.:J MoclerJ.tcly :J \lllllmall\' :.:J :\C't at all

• Comments:

For the next tH'O qucstions, please 1"(:(l.'r j(l \U/lr ugl1l£lus};Jr rht' /Ill/nt.' It iil,' .\tl.'.uT;\ '[I'j'

ics) in this It'Orkshop.

5, Which three sessions were the most useful. and why!

a. ~

b. _

c. _

6. Which three sessions were the least useful. and why)

a. _

EngenderHealth ComprehenSive Counseling for Reproductive Hea!t~-Tra''lers' Manual 249

Appendix EParticipant Evaluation Form '~~~-----'-'----"---~----------------,

6. Which three seSSlOns were the least useful, and why? (continued)

b. _ -------------_.-

--------------------~-_.._._------------~

c. . _

---_._._----_..~-------------

7. Please check any of the following that you feel could have improved the workshop.

a. Use of more realistic examples and application~~

b. More time to become familiar with theory and concepts

c. More time to practice skills ,md techniques

d. More effective group interaction

e. More effective training activities

f. Concentration on a more limited and specific topic

___ g. Consideration of a broader and more comprehensive topic

h. Other

• Comments:

._---------------

8. What three things could the organizers of this training have done to make the trainingmore effective for you?

a. ~ _

b. . ~.

c. _

'---------------------------._._---------------'


EngenderH ealth

Appendix FTrainer Evaluation Form

Comprehensive Counseling for Reproductive Health-Tra:'1ers Manual 251

Appendix F

Trainer Evaluation Form

You have just facilitated a training course on integrated SRH counseling. Please answerthe following questions: these witl help us c\aluate and impro\"C this course from your. thetrainer's. perspective. You may give your form to the organizers of this training, or you ma:- sendit directly to:

Advances in Informed Choice TeamEngenderHealth440 Ninth AvenueNev·.. York., :,\Y 1000 I C.S ,A.Telephone: 212-561-8000 Fa\:: 212-561-fW67e-mail: [email protected]

1. How \\ell did the objectiws of this (L1ur~c' r"'fk .... ( the ~I.;ilb thJt prL)\IJcr~ I1c:J h' ,:.l~ l'UI thclrtasks in integrated SRH counseling')

:J Extremely well

Comments:

:.J Emh \\c!l

2. To \vhat extent were the participants able to ma-;ter the ,I.; II b taught in !he tr:llnlllg'

o Completely

Comments:

CJ Mostly :=J Partiall! o \rinimall\

3. Please evaluate the following aspects of the Trainer>' \Lmual.a. How clear and thorough wae the instmclions I methodology and COOlentl for .... ()ndu .... tlnf

sessions?

:::.J Excellent

Comments:

o Above average :::J Average :J BelowavcrJ.ge

'-------------------------------------_.__._-EngenderHealth ComprehenSive Counseling for Reproductive Hea:th-Tra;nes' '.lar"ai 253

.,.- ~VIOUS P/~GE BLM·lK

Appendix FTrainer Evaluation Form-~--------------....--.------------,

3. Please evaluate the following aspects of the Trainers' Mannal. (continued)

b. Almost all of the content to be covered in this curriculum was included in the Participant's

Handbook. How well did this prepare you to conduct the sesslOns?

o Extremely well

Comments:

o Very well o Somewhat [J Nat very well o Not at all

-------- --_._~-----~--~-

-~-----~._._-_.--~---------~

~. How logical was the sequencing of sessions, both to facilltal':; the transition from session to

session and to faei litate participants' learning?

o Extremely

Comments:

:J Very o Somewhat o Not \Uv o Not at all

____• •• -0-

-----_._---_.. _.._--

4_ Til \vhat extent were the materials distributed to participant:..:

a. Relevant to their learning needs?

o Extremely

Comments:

OVery o Somewhat o Not wry o Not at all

--------------~--------~_..

--------._---~-----------_.._-_.._---~~~-----

b. Adequate in scope and depth for reinforcing their leaming'l

o Extremely

Comments:

OVery o Somewhat r:l Not v:;r-y o Not at all

L-~~

~~

._. ~____J


Appendix FTrainer Evaluation Form~----------------

rs. How would you rate the amount of time allocated (0 each ~e~~lon'). 0 Ideal :l About right:J Adequate :J Slighlly inadequale

Comments:

6. What would you sugge~t to impro\e this traming'~

Please use (hi~ ~pace for more e:\[ensi\c (\lrnrnc'nL-

Thanh. \'OU'

EngenderHealth Comprehensive Counseling for ReproductIve Health-Trainers' Manual 255

EngenderHeallh

Appendix GOutcome Evaluation Using Observation

of Client-Provider Interactions

Comprehensive Counseling for ReproductIVe Health-Tral~ers Ma'Cual 257

FP.r:VIOUS PAGE BLAfJK

Appendix G

Outcome Evaluation Using Observationof Client-Provider Interactions

The true test of the success. or outcome. of integrated SRH counseling traimng IS whether theparticipants are conducting such counseling at their sen'ice sites and how well they are doing it.This and the following two appendixes offer tools for e\aluating the outcome of this trainingthrough observation of client-provider interaction. through interviews with pro\'iders. andthrough anonymous interYiews with clients. All three perspecl1\'<.~s should be con~idered to get acomplete picture of the possible impact of the training on providers and client~, As nl1teJ in"Before the Training Course" (Introduction for the Trainers. page X\li I. trainers should dctemlinethe evaluation plan \vith program planners and site administrator" prior to conductmg the (ourse

The Observation Guides presented here are guiJdine~ for ob'en'ing the -:-oLllbcling interacth)nbetween providers who have been through this training and actml client~. Ob,er.J.:ic'l!l IS bas\'.:~il

ly meant to answer the questions "h the provider applyin? integrated SRH counselin§: skills III

sen'ice dcliveIJ")" and "If so. how well'~" If a baselme ob"cf\'ation wa.;, conducted befNe thetraining, obsen'ations following the training can :.lisa indicate change" in the pro\'iJer', J.ttitUlb,anJ ,,,k.ilh. which may be attributable to the training.

Who Can Conduct Outcome Evaluation?Since competency in counschng is evaluated through oh"'cnation oi C()Ulhclmg and thwughinten'iews with participants and clients. such c\;,jluations are ne-::c~sarily ,'l1I11C\\!1at ,ubjc...'!i\c, T,1make the observation process as reliable as possible from one c\'aluation to anoth"r. the ,arneincli\'iduals should conduct the evaluations each time. ;ll1l1 thc~(' ('\',du;j[,'r'~ ,hl"uLI r>;.' ,,·\.)nT;.·t(':~t

m the sk.ills being evaluated. The trainer:- should nOl do thc e\aludtiolb. although the~' ,,'an hel!'orient local evaluators to the desired outcomes of the training,

When Should Observation of Counseling Be Conducted?

To assess the impact of the training on providers' skills. counseling ohscnat10n need, [,) tx? ...','nducted both before and q!ter the training (for example. thrte ()r six month, followlllg tL.l.ll1ln§: 1, Ifit is not possible to do the "baseline" ohsen'ations before the training. [he Oh,ef\:ltic1n Gude \.'~iI1

still be lIsed following the training. to determine if and how well trainee, Me utllinng the ,kill,learned. (However, you do lose the chance to :.lttnbutc any "improvement" to the trainmgl

How Can This Information Be Used?

The results of outcome e\'a!uation can be used in many ways,

• Program planners and administrators will want to know if the training had the de-;ired effect

on service delivery (i.e" establishing integrated SRH counse ling sen'ices t. If it did not. thesetools provide clues for what the barriers are and whether they are trall1ing-related or can hoctraced to other aspects of service delivery.

• Providers will want to know how clients respond to this approach to counsehng and how they

can improve their skills,

• Trainers will want to know if their training approaches were effectiw in imparting appropriateknowledge, attitudes, and skills for integrated SRH counseling and how thc:->e approa-::he:, (an

be strengthened.

EngenderHeallh ComprehenSive Counseling for Reproductive HeaJlh--Tra!ners Manuai 259F,-~E VIOUS P,;GE BL;j,; ::<

Appendix G

• Finally, EngenderHealth would like to know the outcomes of these trainings in different countries, so that lessons learned can be shared both across the agency and throughout the healthand development community.

Observation Guides

The expected outcome of this training is the improvement of skills in providing integrated SRHcounseling and the effective application of these skills in the participants' service settings. Theindicators of skill improvement reflect the general objectives of the training, which are based ontasks necessary for carrying out integrated SRH counseling, and on the knowledge, attitudes, andskills necessary for carrying out these tasks. The attached Observation Guides provide a guideline for monitoring performance on these indicators.

Two versions of the Observation Guide follow. The decision on which to use depends on whetherthe workshop has used REDI or GATHER as the framework upon which the training is based.

The steps of the REDI framework can be applied to any of the types of services a client may seek(family planning, STI and HIV, maternal health care, or postabNtion care). The evaluator shouldobserve the "general skills and establishment of positive client-provider interaction" throughoutthe visit and apply the indicators of the steps of REDI as the coo:;ultation progresses.

in the GATHER framework, within each step are general indicacors that apply to that task, followed by subsections addressing indicators for family planning clients and STI and HIV clients.The evaluator should observe service-provider performance in tenns of the "general skills andestahlishment of positive client-provider interaction" throughollt the visit and should apply the"generic" indicators for each step of GATHER for all clients. For family planning and STI andHIV clients, the evaluator can also observe the specific indicators given.

Specific Instructions• To help improve providers' skills, as well as the training itself (see below), the completed

Observation Guides will be shared with others; thus, these forms are not confidential. Theprovider should be made aware of this before the observations begin.

• Ideally. the evaluator would observe each provider interacting with several clients. The Observation Guide provides columns for rating up to four interactions. It an observer evaluates morethan four client-provider interactions for one provider, additional fomlS should be used.

• A separate Observation Guide should be used for each provider evaluated.• Following the observations, the evaluator should meet with the provider to discuss them.• Copies of the completed observation guides should be given to the provider, to the provider's

supervisor, and to a representative of the training team. The evaluator should give the originalforms to a local EngenderHealth staff member or send them to:

Advances in Informed Choice TeamEngenderHealth440 Ninth AvenueNew York, NY 10001 U.S.A.Telephone: 212-561-8000Fax: 212-561-8067e-mail: [email protected]

260 Comprehensive Counseling for Reproductive Heallh-Trainers' Manual EngenderHealth

Appendix G

Observation Guide: REDI Framework

I ::;; Needs improvement2::;; Adequate.3 ::;; CompetentN ::;; Not applicable

fns/me/ions: Evaluate the performance of the provider in implementing each ta,1.; L'f ~lCtl\l!~_ u~ing thcfollowing codes:

Service site:----------~---

Date -----------

Name: _

Observer: _

Observation Guide: REDI~=====<============~====-===--~=-

Task/Activity

Rating perclient-provider

interaction

General skills and establishment of positive client-provider interaction

Demonstrates respect for the client: does not Judge the client

Shows friendliness by smiling----------

Ensure~ pri\"acy In the consultation room

Uses simple and clear language

Asks open-ended questions

Asks the client LO paraphrJse. as necessary. 10 ensure that the cliemunderstands his or her questions and explanations

Encourages the client to ask questions and expres~ concem"

Answers all of the client's questions

Indicates throughout the consultation that he or she is listenmg to the client

Paraphrases the client to ensure understandmg of the chent's mcs~age

Assures the chent at confidentlaltty

I Does not interrupt the client uiliess absolLneh ncccssan:-

REDI

Rapport-building

Welcomes the client with \varmth and with respect

Offers the client a seat

Introduces himself or herself

Identifies the reason for the client's \-isit .

Introduces the subject of sexuality and explains the need to ask. certainpersonal questions

,

Explains what \\ ill happen during the \"isit (as appropnate)

EngenderHeatth Comprehensive Counseling for Reproductrve Heaith-Tra:ners" Manual 261

~. -Rating per

client-providerTask/Activity interaction

Exploration

Asks the client about:

• His or her needs, problems, and concerns..~

• His or her sexual relationships. including:----~

>- Sexual relationships in which he or she is involved."_.

>- Concerns about violence or abuse~-

>- Client's communication with a partner about sexuality, familyplanning, and HIV and sexually transmitted infections (STls)

-_."..-

>- Client's knowledge about partners' sexual behaviors outside ofthe relationship

--."-'.Asks the client about his or her:

._~._-~_.,-,.._---,--

• Pregnancy history.~

• Knowledge and use of family planning methods, including condom"._-_.._,"---

• HIV and STI history and symptoms.._---

• Knowledge of partners' HIV and STI history-,-.

Asks the client about his or her ability to make his or ber own decisiom.on having sex and about the influence of any of the following factors: __...

• Client's financial dependency on his or her partner(s)

• Pressures from extended family--

• Fear of violencew___, ••_._

Asks the client what he or she knows about:-~_ .. -

• Pregnancy-related care (if appropriate)._-,,-

• Postabortion care (if appropriate)

• Family planning

• HIY_ ..

• STls..•. ,,-.

Provides the client with information about the above topics, as needed-_._--

Helps the client determine his or her (or his or her partners') risk for:_~

• HIV and STI transmission

• Unintended pregnancy

Decision making

Helps the client determine what decisions he or she needs to make tod~IX

Explains the importance of the client's making his or her own decision:,

Helps the client consider all of the alternatives and options --

Helps the client consider the pros and cons of each alternative or option(including side effects and the possibility of complications)

.._,.

Appendix GObservation Guide" REDI


Appendix G

a mg perclient-provider

Task/Activity interaction

Decision making (continued)

Provides additional infonnation. as appropriate. to help the client comideralternatives and options

Helps the client consider how his or her fami!: might react to his or herchoice of alternatives

Helps the client make his or her own decision. regardles, of the Vle\\, of other'

Asks the client to explain in his or her own word, wh~ he or she madethe particular decision

Helps the client assess whether his or her deCISion could actually ~ carriedout \gi\"t~n relationships. family situation. ,XlllHlIllic "t,ttu,. et ...·. i

Implementation

Helps the client make a plan for carrying out the deCISion. askmg:

· \Vhen are you going to do what you decided to do!

· Under what circumstances are ~ ou goin~ to dll III.._- - ~----~-

I Observation Guide: REDI----------------------R----or--

I'.\\ hat Will your next steps be)

Asks about:____ _ ~ ~

• Possible consequenct's Of. the client's plan JpoteJltial health ~nejib \·s.risks. partners' reactions. client's concern, about economIC 'upport.client's concerns about VIOlence. etc.l

• The client's ability to communicate his or her plan to partners1-----------=----------------''-----------'----------------------

Asks about social supports or barriers: ...

• Whom the client could count on to support him or her in th .... dc-:i'lon

• \\'ho might create ob:-tacles. and what the chent (an do aboutthat if it happem

------------_ ..__ .Helps the client make an altematt' plan if thi:- one doe" not work I)Ut

Helps the client Identify skills needed to ...·arry out thiS Je...·lswn1----'-----------------------------------------

Helps the client develop commuT1lcation and negotiation "kiJ b (;1' nece SS:l0 } ,--__. . _

• Discusses the client's concern, about communicating and negotiatIngwith partners or other family members concerning: this deCision

• Offers ideas for improving commuIllcatlon and n<.'gotiation

• Helps the client practice communicating through rok plays

Helps the client develop condom-usc skills (as necessary): -_- _

• Demonstrates to the client how to use a condom and has the chent repeatthe demonstration to reinforce his or her underst;mding

• Discusses how the client can make condom use more acceptable to hIS

or her partners

• Gives the client samples of condoms and tells him or her where and hO\\

to obtain more

EngenderHeallh Comprehensive Counseling for Reproductive Heallh-Traners Manual 263

Task/Activity

Appendix G,Observation Guide REDI~--------------------_._--------=----:-------,


interaction

Implementation (continued)

Helps the client develop other skills in using family planning methods .-_.-_r-__.--_I

• Asks client to state in own words how to use the family planningmethod chosen by the client

--------=-------~----------------~-_.~-----+---+--+--+--j

• Helps the client plan how to manage common side effects andwhat to do if warning signs occur

r~:------=--_::_:_--,__-,___,_,___--,__-----------·----·--··-·-------L.--'--....L----L.-___1

Helps the client make a follow-up plan: -.---_-.---_-.-_-.-_I

• Explains timing for medical follow-up visit and/or contraceptivere-supply and schedules visit (as needed)

--------------• Invites the client to come back at any time for any reason

(e.g., for ongoing support with decision making, negotiation, etc).------ --------t-'--t----j--_+_----f

• Refers the client for needed or requested services unavai lable on-si tef------,----------------------------··-----------t--t---t----1

Asks if the client has other comments that he or she would like to sharethat have not already been covered by the questions above


Appendix G

Observation Guide: GATHER Framework

I =Needs imprO\"ement2 = Adequate:I = CompetentK = ;-;at applicable

Instructions: Evaluate the perfonnance of the prO\"ider in impkmentmg each ta~~ l1[ a..:t1\I!;'. u-mg the

following codes:

Service site: _

Date

Name: ~ _

Observer: _

Observation Guide: GATHER =====.....,.=~=~=="""""======.-.-======

Task/Activity


interaction


Demanstraks respect for the chent: does not judge the client

~ Shows friendliness b\ smilim! 0--------

, En'lm~s pri\"acy in the consultatlon room

lises simple and clear language

i ,-'\sks open-ended questions

c-------------------------------------------

Asks the client to paraphrase. as necessary. to ensure that the c!lenlunderstands his or her questions and explanatIOns

Encourages the client to ask questions and express concerns

Answers all of the client's questions

Indicates throughollt the consultation that he or she is li~tening to the- (hem

Paraphrases the client to ensure understanding llf the ,,: hell'" ~ IllL' "~l.::e

Does not interrupt the client unless absolutely necessar:

GATHER

Greets and welcomes clients

Greets the client with respect and kindness. introduces hlm~elfor h~r~e1f.

and offers the client a seat .

Asks what he or she can do for the client: detennines the purpo~e

of the visit

Explains what \\lll happen during the \ isit

Assures the client of the confidentiality of all infonnation that l~ ,klreJ

Encourages and responds to the dient's questions

EngenderHealth Comprehensive Counseling tor Reproduct:ve Heallh-Tra:ners' ~lanual 265

,.- ---------Rating per

client-providerTask/Activity interaction

Asks clients about themselves and their concerns.M_··_'·__

Assists the client in: .,--

• Clarifying his or her reproductive health needs, concerns, and probkms.,-,.

• Asking questions--,..

• Determining decisions or actions that the client needs or wantsto make during this visit

--'.

Obtains the client's medical and social history (as appropriate to the cli,~nt's

needs and concerns, using the checkli sl for the corresponding service) :._

• Asks simple and brief questions

• Explains terms as needed._-.-

• Explains the romine nature ane! purpose of risk -assessment question';regarding pregnancy, sexually transmitted infections (STIs), and H [Vor AIDS, among others

.-.._--

Asks about the client's:~--'-'-'~-'

• Reproductive health plans (desired number of chi Idren, spacing ofbirths, etc.)

.~-_._._---..~-

• Perception of risk (regarding pregnancy or STls, and HIV and AIDS)

• Risk behaviors as pertinent to the client's concerns (e.g., pregnancyand STIs and HIV)

-------.-

• Other health, interpersonal, or social concerns.._-----""

• Feelings about their concerns, risks, etc. (as appropriate)"-""-

Explains the purpose of the questions (as appropriate) __"_R_

Looks at the client while he or she (the client or service provider) speah

Encourages and responds to the client's questions

Tells clients information appropriate to their SRH needs and knowledge... ~

Begins the discussion with the client's preference or mO.';t urgent need-~--

Asks what the client already understands about his or her SRH situationand desired course of action -_.._--

Tailors information to the client's need, knowledge, and personal situatiun~ ..

Uses words familiar to the client~

Uses appropriate information, education, and communication materialsin an effective manner

Asks open-ended questions to verify the client's understanding of importantinformation

---_..,~

Encourages and responds to the client's questions""

Corrects false information and rumors, as needed--,..--

Appendix GObservation Guide" GATHER


Appendix GObservation Guide: GATHER ----- ~

Task!Activity

Helps clients to make decisions to meet their SRH needs


interaction

Through active listening. includmg asking open-ended questions, helpsthe c1ient:~~~ ~ ~ ______;

• Take "ownership" of his or her problem and responsibility for hisor her decisions

• Identify options and pros and cons of each

• ~'1ake decisions based on weighing pros and I;on, of all options(including side effects and the:" possibility of compliCaIIOm).relative to the client's values and social contcxt

• Act on decisions taken _

> By asking concrete, specific questions about qeps to he taken

> By encouraging the client in te:"0l1S of steps taken

Confirms the client's decision

Assists the client to identify: _

• Possible barriers to implementing the deCision

• \Vays of overcommg these barriers

Assists the client to practice skIlls le.g .. communication skillslto mercomebarriers (if appropriate)

For clients who decline treatment ()f chl)("',e not to practice any J->eha\'\or change" ._

• Explains possible complications or consequl'nccs of unmanaged condItionor unchanged behavior

• Offers his or her sen'ices If the chent wishes to usc them later

Explains instructions for managing SRH problemlimplementing decisions

Explains hO\v to use the chosen method or tre~tlllent option

Reviews common side effect.;. the wammg sigm or symptoms of moreserious complications. and wh~t to do If thl'y occur

Provides written instructIons :md reviews them with the client

Asks open-ended questions to venfy the clil'nt's understanding of Importantinformation

Encourages and responds to questions from the client

Return visit/referral

Sets up follow-up visit. as needed

Invites the client to come back at any time for any reason

Refers the client for needed or requested services unavailable on-site

Thanks the client for coming

EngenderHealth Comprehensive Counseling for Reproductl·...e Heailr,-T'a'ners' ManJa! 267

Appendix HOutcome Evaluation Using Provider Interviews

EngenderHealth ComprehensIve Counseling for Reproductive Health-TraIners· Manual 269

F8r:VIOUS PAGE BLAf-n{

Appendix H

Outcome Evaluation Using Provider Interviews

The true test of the success. or outcome. of integrated SRH counseling training i.. whether theparticipants are conducting such counseling at their sen'ice sites and how \\dl the: are Jl)lI1~it. This and the appendixes immediately preceding and following it offer toob for c\J.lu:.itJllfthe outcome of this training through obscn'ation of client-provider interaction. through lJHCfviews with prodders. and through anonymous interviews v,:ith clients. :\ll threc pcr"['I..'(!j\C ..should be considered to get a complete picturc of the po.;;sible impact of the trJintn~ l)nproviders and clients. As noted in "Before the Training Course" (Introductil)!1 It)r the Tr.lIi1C[ ...page xvii). trainers should determine the c\'aluation plan with program planner .. and .. Headministrators prior to conducting the course,

The Provider Interview Form giH~s a template for exploring the individual prO\lc!cr· ... l"Cr'i~('tive on how well he or she has been able to apply what he or she learned 111 the tr~lIl11n.:::..mJwhat challengcs may have been encountered. It is meant to complement the Infornutl('!lprovided in the Obscr-\-ation Gtlide~. ;lnd to ~Uh\\Cr the quc:;tion "\Yhy not'" If it ;, f,lU:"J :::..::the provider is not implementing integrJ.tcc! SRII coun~cling with client... It ~lt..l) rCljuc,r.. ,u,;gestions for impro\'ing the training.

Who Can Conduct Outcome Evaluation?Since competency in cOLlnseling is evaluated through obser\'J.tlon of counseling :lnd [h[\)u~hinterviews with participant' and clients. "lIch cvaluation" ~lre nc-ce""'arily 'nme\'. h~~t ".lhlstl\CTo make the obsCl'vation process a~ reliable as po-;:-.ihlc from one cV;lluatlon [() ~trj()t)k'r. thesame indinduals should conduct the evaluations each time. and the ..e c\alu~H(lr"h\)uLl [1.-...'competent in the skills being evaluated. The trainers .. hould not do the c\aluatinn .... ;tltlhlu;hthey can help orient local evaluator" to the desired outcomes of the training.

When Should Provider Interviews Be Conducted?Since this interview renects on the pro\'ider's experience foIlO\\'ing the tr~llmng. It Wl'tild "l1hbe carried out at the time of the ro.. ttraining oh"ervations.

How Can This Information Be Used?The results of outcome c\'aluation can be used in many ways:• Program planners and administrators will wanl to know if the traiIllng h~lll th", J,..... lred

effect on service delivery i i,e .. establishing integratcd SRH counseling ,enlL'C' I It][ lll..!not, these tools provide clue" for what the barriers are and whether they are trainmg-rebrcJor can be traced to other aspects of sen'ice delivery.

• Providers \vil1 want to know how clients respond to this approach to coun,c1ing a.nJ h{)\\they can impro\'e their skills,

• Trainers will want to know if their training approaches were effecti\c in imparlIng J.ppropriate knowledge. attitudes, and skills for integrated SRH coun"el ing and l)()\~ the ... eapproaches can be strengthened.

• Finally, EngenderHealth would like to know the outcomes of these training.; In dlffl'rent

EngenderHealth Comprehensive Counseling for ReproductIve Health-Tralne~s Manual 271

Appendix H

countries, so that lessons learned can be shared both across the agency and throughout the

health and development community.

Specific Instructions

• The evaluator should fill out one form for each provider interviewed.

• To encourage candor in the provider's comments, the linterviewer must maintain confiden

tiality. Therefore., the provider's name should not be recorded on the fonn. The site name

also should not be recorded on the form, since there may be only one provider interviewed

at any site, and this would allow the individual provider to be identified.

• The evaluator should compile a summary of the providers' interviews after at least four

have been conducted in at least two sites. The summary only should be shared with the

supervisors, site or program managers, and a repre~emative of the training team. This

should be explained to the provider before the interview is started.

• The evaluator should give the original interview forms and a copy of the summary to a local

EngenderHealth staff member or send them to:

Advances in Informed Choice Team

EngenderHealth440 Ninth Avenue

New York. NY 10001 U.S.A.

Telephone: 2]2-561-8000Fax: 212-561-8067

e-mail: [email protected]

If the provider answers Question 1 by saying he or she has "not found it appropriate to initiate

SRH counseling with clients," make notes on why this is so, and then skip to Question 5 and

complete the rest of the interview. Questions 5 through 8 ask specific questions about prob

lems that have been encountered, and these would definitely be relevant for a trainee who has

not done any SRH counseling with clients.


Appendix H

Provider Interview Form

Intef\'iewer: ~ Date: _

InstructionsObtain a copy of the participanr's action pl<m (from Session 31 of the training I ahead oi lIme(for Question 7).

Introduce yourself. Explain to the service provider that:•

, .

•

•

The purpose of the counseling: training that you partICipated In wa" tn ITnprow y()1.J[ c('un~

seling skills to address the range of clients' SRH needs and concerns.

The purpose of this inteniew is to learn how you han:: hecn aok to aprly y,'t!r training tothe provision of SRH services. the challenges you may hJ.\c encountered, and how thetraining might be modified to better prepare panicipanh for counse!lOg w.:--k:; in SRH 'Cf

\ice provision.

~lany of the questions are open-ended questions th:..Il enable you nhe sen'iL'c pro\'iJer i t\)share your responses and reactions without being confined to a rreJeterminl'-l Ltr1fl' l,ranswers.

The re'ltlts of this inten'ie\\' with you and other p;trticlp:lTll' '.\·ill l)c ,h:lrcd WIthprogram managers. supervisor;;, and trainers, to make 1l11proW!t1Cllh ;It your work "itl' an,lin the training itself. If there is only one trainee from Yllur work. site. It may he dirh.:ult :1!

not impossible) to ensure confidentiality. Howe\'t~r. canuor wIll he ;,pprl.'l'iJtcJ ;tnJ \\illyield the most helpful responses.

Questions

Check off the service provider's response to each que~tioJl. or fill in adJllional exrIJ.JlJt!un.as appropriate,

1. What has been your experience in counseling clients in SRH since you partlcipatt.:'J In theintegrated SRH counseling training'?

::J I initiate counseling with all clients,

:l I initiate counseling with certain kind" of clients. E\dlllPlc,,:

o I have not found it appropriate to initiate SRH coun~eling:with client:-- [Go to QuestIOn5]. Explain:

EngenderHealth ComprehenSive Counseling for Reproductive Heatlh~Trainers' ManLiai 273

Appendix H

IProvider Interview Form ._~-----

2. What has been the reaction of clients when you have initiated SRH discussions with

. them? (check as many as apply)

o Clients seem to have welcomed the discussions (have been open and interested in

discussing their issues).

o Clients have seemed uncomfortable, but have answered questions when asked.

o Clients have been mostly closed or resistant to discussing anything beyond the primary

reason they came to the facility.

3. What do you do to establish rapport and trust with clients?

---~---------~-----_

.__._.._..

_.~--_._-_ .._-_ .._---------

4. Consider various areas of counseling that were emphasized in the training.

(a)Helping clients identify {lnd address their individuol SRH needs, including the social

and sexual context

• Describe your approach.

~--~------------------

--------------_.__.-.._----------~---

• How effective do you feel this approach has been? Explain.

• What obstacles have you encountered in using this approach?

L-. -----l


Appendix HProvider Interview Form ---------------------

(a) Helping clients ide1lt~fy and address their indiddual SRH needs. includl7ll! lht' socia!and sexual collte..t (continued)

• What have you done when confronted by these obstacles') What suppt,n or J.~:-IS

tance do you need')

(b) Gil'iJlg essential inlormation (() chow


• How effective do you feel this approach has been') Explain.

• What obstacles have you encountered in using this approach')

• \Vhat have you done \vhen confronted by these obstacles) What ~lIrrt)rt or a.... sisrance do you need')

EngenderHeallh Comprehensive Counseling for ReproductIVe Health-Trainers' Manual 275

Appendix H- Provider Interview Form----~----~ ~~----"-~-------~-~-------,

(c) Helping clients assess their own and their partners' risk of unintended pregnancy or

HIV and STI infection


• How effective do you feel this approach has been'? Explain.

--_._-----~_ .. ---~------~.

• What obstacles have you encountered in using ;,his approach?

• What have you done when confronted by these obstacles? What support or assis

tance do you need?

(d) Helping clients reduce their risk


276 Comprehensive Counseling for Reproductive Health~Trainers'Manual EngenderHealth

Appendix HProvider Interview Form-------- _

(d) He/pin!? clients reduce their risk (umtil/ued I

• How effective do you feel this approach has been'? Explain,

• What obstacles have you encountered in using this approach')

• \Vhat ha\'e you done when can fronted 0\ these obstac les) What support l,r a--Sbtance do you need')

--------- -.

~-------------------------------------

(e) Helping clients make their Oll'll deci,~iolls

• Describe your approach,

• How effective do you feel this approach has heen') Explain,

EngenderHealth Comprehensive Counseling for Reproductive Health~Trainers '.~a'1c;ai 2n

Appendix HI Provider Interview Form --.-"-----

I (e) Helping clients make their own decisions (continued)


• What have you done when confronted by these obstacles? What support or assis

tance do you need?

---_.._-"- .._-_.- .__ .

(j) Helping clients implement their mvn decisions. Risk assessment


• How effective do you feel this approach has been? Explain.

------------------_.--._----------------

.-_._--~~-----

--------



Appendix HProvider Interview Form----- _

if) Helping clients implement their {)Il'fI decisions: Risk iIS\CSSl7lefl{ I continued}

• Vv'hat have )/OU done when confronted by these ob~wcle....) WhJt ~upport or ~b~I~

tance do you need?

(gJ He/ping clients communicate \\'ith a partner aholtt SRH concems


• How effecti\'e do you feel this approach has been') E.\plall1.

• What obstacles have you encountered in u"ing thi~ appwach)

• What have yOll done when confronted by these oostacle, ) What support or assistance do you need?

EngenderHealth ComprehensIve Counselmg for Reproductive Heatth-Trainers' Manual 279

Appendix HProvider Interview Form.----------

5. Remind the provider that the general objectives of the training were to enable partici

pants to carry out the following tasks:

• Help clients assess their own needs for a range of SRH services, information, and

emotional support

• Provide information appropriate to clients' identified problems and needs

• Assist clients in making their own voluntary and int4.mned decisions

• Help clients develop the skills they will need to carry out those decisions

Ask him or her to consider the following questions in terms of their ability to carry out

these tasks.

A. REDI or GATHER

• In what ways has REDI or GATHER been uset\tl in carrying out these counseling

tasks, listed above?

• What problems have you encountered in applyi ng REDI or GATHER?

B. Open-ended questions

• In what ways have they been useful?

• What problems have you encountered in posing them?


Appendix HProvider Interview Form _

C. Listening

• In what ways has this been useful"

• What problems have you encountered in applying this skill"

D. Paraphrasing

• In what ways has paraphr;lsing been u-.;eful'.'

• What problems have you encountered in applying it')

6. ,"Vhat types of clients. clients' attitudes. or clients' beha\'iors do you find !11L1.. t ckdknsing in SRH counseling?

EngenderHealth Comprehensive Counseling tor Reproductive Health---Trainers Manual 281

Appendix H_Provider Interview Form ------------ ._--_.... -------------------,

6. What types of clients, clients' attitudes, or clients' hehaviors do you find most challenging in SRH counseling? (continued)

• In what ways are they challenging to you?

--- ..._------------.._-_._------

• What do you do when confronted by these clients, attitudes, or behavior?

7. How would you descrihe your progress in implementing your action plan?

• What obstacles have you encountered in implementing your action plan?

----_._-----------~.__._---_ .._---------_._--

------------------_.--~---_.

• What success have you had in overcoming these obstacles? What additional support orassistance do you need?

------------------


Appendix HProvider Interview Form .

Is. What <uggestions do yOll have for improving the training. to bener prepare p"n'dr"nt-I to carry out the task..;, ot Integrated SRH counse!lng·1

---------------------------------~----

EngenderHealth Comprehensive Counseling for Reproductive Healtn-.-.T:a,l1e's Mar'J3' 283

EngenderHealth

Appendix IOutcome Evaluation Using Client Interviews

Comprehensive Counseling for Reproductive Health-Trainers· ManClai 285

PREVIOUS P,t,GE BLAr:K

Appendix I

Outcome Evaluation Using Client Interviews

The true test of the success. or outcome. of integrated SRH counseling traiom,g is whether theparticipants are conducting such counseling at theIr sen'ice sites and how well they ilre domgit. This and the preceding two appendixes offer lOols for evaluLl.ting the outcome of this training through observation of client-provider interaction. through ioten'iews with pw\idcr~.

and through anonymous inten'iews with client'>, AI] three perspectives should be cCln.;iJereJ toget a complete picture of the possible impact of the training on pro\'iders and client.;, As nCl[edin "Before the Training Course" (Introduction for the Trainers. page x\'ii I. trainer, ,houlJ

detennine the evaluation plan with program planners and site aclminJstral0r~ rnl)r to cc'nJu((1I1g the course.

The Client Tnten'iew Form included here is to he L1"ed to gather feedhack fn.m client" ar('L1(their perception of the quality of the counseling sen'ices they haw recei\'cd. ,-\gain. it I" he ... tused in conjunction with the Observation Guide" and Prmicler IrHen'iew Form,

Who Can Conduct Outcome Evaluation?Since competency in coullseling is e\'aluated through Oh"ef\;ltinn of counsdin~ JnJ thr,lu~h

intervic\\is with p3.rticipants and clients. such e\alu~ltion:-. arc nccc,,:-.arily "omewh..H ,ubjc(li\t'To make the observation process ~L" reliable a" po""ible frum nne e\aluatil)n t,) ,lIll)thcr. ttl,-'same individuals should conduct the evaluation" each time. and these e\aluatC1r" shnuld r.~

competent in the skills being c\'aluatcJ, The traiih.'r"h\luLlllu! ,10 {hi.? C\.del.lll,);;' .• ltn,'u::hthey can help orient local evaluators to the desired outl'ornes of the training.

When Should Client Interviews Be Conducted?Client inten'jews can be conducted both before and after tht~ training. to get ,,0me "ensc l.t" th.:clients' perceptions of change over time, Since other factor" may influence qua!lty (Of can: ..mJclients' perceptions of it. changes in quality (from the client'" perspective I cannot he directlyattributed to the training. However. these intCf\·ic\\.; may yield \aluabk in~l~hh InW theclJents' experience. which can be add[(~"scd in future [rai ning" nr trainll1t,: f( 1 !Il)\\" - i.ll'

How Can This Information Be Used?The results of outcome evaluation can be used in many Wa\y

• Program planners and adminisrralors will want to know if the training" had the Jt:>ircJeffect on sen'icc delivery (i.e .. estilolishing integrated SRH counschng ...en·ice" i. If it did

noC, these tools provide clues for what the barrier" are and whether they '-ire trail1lnf-reLiteJor can be traced to other aspects of service delivery.

• Providers will want to know how clients re'pond to this approach to coun~cling and hlw.they can improve their skills,

• Traillers will want to know if their training approaches were effective 111 impartll1g appropriate knowledge. attitudes. and skIlls for integrated SRH coun"eling Jnd how the,;:

approaches can be strengthened.

EngenderHealth Comprehensive Counseling for Reproductive Heallh-Trarlers ~/an0aj 287

r,r:\fIOljS pLi"::r Bl 1',':;1••. .... J '\...IL _lll',;\

Appendix I

• Finally, EngenderHealth would like to know the outcome<., of these trainings in differentcountries, so that lessons learned can be shared both acro:;·s the agency and throughout thehealth and development community.

Specific Instructions

• The client's name should not be recorded on the interview form, to maintain confidentialityand to encourage the client to be comfortable giving feedhack that he or she may believe iscritical of the provider or the service site.

• The site name should be recorded, however, since this feedback would be valuable to sharewith providers and supervisors at each site.

• The evaluator should compile a summary of the providers' interviews after at least fourhave been conducted in at least two sites. Copies of this summary should be given toproviders and supervisors at each site, plus to a representative of the training team.

• The evaluator should give the original interview forms and ,I: copy of the summary to a localEngenderHealth staff member or send them to:

Advances in Informed Choice TeamEngenderHealth440 Ninth AvenueNew York, NY 10001 U.S.A.Telephone: 212-561-8000Fax: 212-561-8067e-mail: [email protected]


Appendix I

Client Interview Form

Interviewer:---------------------

Site: _

Date: _

If the client agrees. proceed wi!h the interview using the followmg qUe:'stlon", Recnrd rheclient's answers in the spaces provided, Check the column ":\.~" if the QUC:,tlt111 i" nnt

applicable to the client you are interviewing.

InstructionsIntroduce yourself to the client and explain that:

• You are inter;iewing clients about their experience In "eeking ~md nhratnlng SRH "ervices at this facility.

• The purpose of your inten'iewing clienh i,,> to get feedback ahCll-1[ thell rer....erti(H" l)f thequality of services they received, This will enahle facility <;[3ff to c0ntinuc t,.-, imrrC'v\.' thequality of their services,

• In this context. you would like to ask the client some queqion" anour the ,cr\ icc:, he orshe just received, The client's answers will he "yes" or "no," You will not Ix- a:;kin~ anyquestions about the client himself or herself.

• It is important that the client he frank about his or her impressions. tl' help elmlC !X'rSt'nnel impro\'e. The client's feedhack will be anonymous-thaI J:-. n(, name, will tx: ((In

nected with his or her responses.

• Ask the client for his or her pem1ission to be interviewed for thi" purr",,,,• ThIS will take about 15 to 20 minutes. Would he or she have lime:' for !ha!'

iIILClient Interview Form ==~========================

Yes No NA


In general. did the stafr \lith whom \'011 met: ~__

Show you respect (did not judge you. what you think. or what you ha\t' J0nL' I')

Ensure your privacy in the consul!ation room')

Talk in a language and use tenns that you could easily understand')

Ask you !o repeat some of the ex.planations to reinforce your undcNanding')

Listen !o you without intemlpting and show interest in what you had to '<i)' .,

Encourage you to talk about yourself and !o ask questions')

Answer your ques!ions clearly')

EngenderHealth Comprehensive Counseling for Reproductive Health-Tramers' Manual 289

I

Yes No NA_.._~-

Rapport-building-,..

Did the staffwith whom you met:

Welcome you with kindness and with respect?.._,._-

Make you feel comfortable?-

Introduce himself or herself?----_._--~

Ask what he or she could do for you?--"-"

Explain why he or she would be asking sensitive and personal questions'!.._,._-.

Assure you that whatever you said would not be shared wlth othcp;'J-,..

Explain what would happen during the visit?

Exploration.._..

Did the staffwith .vhom you mer:-._.--

Ask you about: _________'UT_."_

• Your sexual relationships?.._.,.._~

• How you communicate with your partner (or partners) abollt s,:~xLJality,

family planning, HIV, and sexually transmitted infections (STTs)?

• Your knowledge about your partner's (or partners') sexual behaviorsoutside of your relationship?

.._"

Ask you about your: ---_.-

• Previous pregnancies, and the outcomes of those pregnancies?---

• Use of family planning methods, including condoms?

• Own HIV and STI history?

• Knowledge of your partner's (or partners') history of HIV or STTs?-

Ask you how you make decisions about your own sexual andreproductive health and behaviors?

.. _ ..••••0.0_, -

Ask you what you know about: -----

• Pregnancy-related care, including antenatal care, nutrition, exercise,or rest (if appropriate)?

• Postabortion care (if appropriate)?

• Family planning?---

• HlV?

• STls?

• Provide you information about any of the above (as appropriate)?._,.

Explain your possible risks for:

• Pregnancy?~_ ..

• HIV and STIs?--

--.,_.

Appendix ICrent Interview Form


Appendix IClient Interview Form ----------- _

Yes No, NA

Exploration (continued)

Help you determine your (or your partner's) risk for: -------------,------r---

• HIV or 511 transmission')

• Unintended pregnancy?

Ask you about other health needs or concems'~

Decision making

Did the staff with H'hom VOli met: - ,.--__

Explain the importance of making your own decisions':'

I Ask if you already made a decision ':'

If you had, ask you to explain in your own words why you made the declswn)

, Help you consider all of your options:

Help you consider the advantages and di'ad\"antages of each option(including common side effects of family planning methods being considered ('

Help you consider how your partner or family might react to your chl1!CC

of options?

Help you confirm or make the decision that yOll feel best fits your medicaland personal circumstances~

Help you receive the sen'ice (lr method y(lll \\'anted. or understand \\ h~a different option \vould be considered better for you')

Implementing the decision

Did the sraffH'ith IdIOm YOll met: ~ _

Encourage you to think about how you would put your decisions into pradlce,'

Ask you: _

• How you would commllJl lcate ) our plan to your partner')

• Whom you could count on to support you in your decision')

• Who might create obstacks for you, and what you can doabout that if it happens"

• To offer ideas for improving communication and negotiationwith your partner?

Help you make an alternate plan if this one does not work out"

Demonstrate how to use a condom (if applicable) and ha\'e you repeatthe demonstration to reinforce your understanding?

Give you samples of condoms and tell you where and how to obtain more'

Give clear instructions about how to use the medical treatmentrecommended for you or the family planning method that you chose'

Invite you back for a follow-up visit (for ongoing support withdeciSIOn makmg, negotiation. or condom use, as appropnate)':

EngenderH ealth Comprehensive Counseling for Reproductive Health-Trainers' Manual 291

Appendix I- Client Interview Form ---------------------.-------~-~--r__-.__,

Yes No NA1------------------------------------'----'----'-------j

Implementing the decision (continued)

Tell you about other services available elsewhere and how to acce\s them?

Were you happy with the service you received?1-------::---'--------'---------------------------+--1---+.-----1

Would you refer a friend or relative to this service provider?

What other comments would you like to share that we have not C\lvercd in these questions?

Is there anything that the provider could have done differently to better meet your needs?(If the client says yes, ask for his or her suggestions and \vJ;te thos here.)

~--------------------------------------------'


EngenderHealth

Appendix JUsing Visual Aids to Explain

Reproductive Anatomy and PhysiologyTransparency Guides

Comprehensive Counseling for Reproductive Health-Trainers' Ma'1ua! 293

Appendix J

Using Visual Aids to Explain Reproductive Anatomyand Physiology-Transparency Guides

This appendix provides a set of simple drawings showing different aspect-. of the male anJfemale reproductive systems. to accompany Session 17. These drawings should t'e made !ntPtransparencies. (See the Training Tip on page 94. if you are not able to u:-e transparencIes. 1 B~

presenting the transparencies in sequence flaying one on top of the others he low I. ~ l)U .:.tndemon:;trate in a simple. step-by-step manner the complexity of the internal organs and hl'\\they interconnect. (See Session 16 in the Participant's Handbook [page 7.:') f(1[ sImple explanations of what the organs are and how they work)

You should allot about 15 minutes to go through the transparencies for the male an;lwm~ ~H1d

physiology and about 10 minutes to cover the female anatomy and physiology' \lore time i:allowed for the male because it is a little more complicated to draw and kcau"e the p,miclpants tend to be less familiar with the male reproducti\'e "ystcms than with the felll<lk repr(\ductive systems.) Practice ahead of time to be sure you can do this. building In tlIne for theparticipants to make their own drawings and for a few que"til\Ib tl) he al1s\\crcJ.

EngenderHealth Comprehensive Counseling for Reproductive Hea:!t~-T falners Manual 295

psr=V10US PAGE BLANK

Appendix J

Male -1

EngenderHealth Comprehensive Counseling for Reproductive Heaah-Trainers ManJal 297

F'RF\,'IO: IS Ot/'~ r: Bl t· ",F'- '_ ; .' \ I._~ 1_ '. I \

Appendix J

Male-2

EngenderHealth Comprehensive Counseling lor Reproductive Health-Trainers' Manual 299

Appendix J

Male-3

EngenderHealth

~:~(v:ous PhGE BLAfJK

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EngenderHealth

Appendix J

Male -4

Comprehensive Counseling for Reproductive Health--Trainers Manual 303

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Appendix J

Male- 5

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Fr:: EV10US P'£~GE BLArJK

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Appendix J

Female -1

o

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Appendix J

Female -2

Comprehensive Counseling for Reproductive Healh-Trainers' Man;Jal 309

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Appendix J

Female-3

EngenderHealth Comprehensive Counseling for Reproductive Health~Tral~ers' '.~anua; 311

Appendix J

Female-4

EngenderHeallh ComprehenSIVe Counseling lor Reproduclive Heal:h-T,anB,S Manual 313

D: l"'E 'BL" f' '/I " '1 1'1.:\

References

EngenderHealth. 2000. Introduction to men's reproducti\'e health sen·jces. :"tW York..

EngenderHealth. 2002. Integration ofHIVISTI preTention. sextll1lity. and dual prorecrion in .t~llni

Iy planning counseling: A training manual. Working Draft. Volume 1-\1anual: \L"llumc ~Handouts. New York.

EngcndcrHealth. 2003. COl/nseling the postahortion client. A rmining curriculum :\ew York.

Gordon. G.. and Gordon. P 1992. Counselling and sexwl!iry. Lonc!nn: Imem~Hi("lnal PlannedParenthood Federation.

International Institute for Environment and Development (liED l. ~OOO. HelpJtl5 :\GO :--taff I anJthe community groups) analyse reproductiw health and gender h"ue,. PLA Y{)tcs 3-:.pp. 31-37. London.

Jain. A. K 1989. Fertility reduction and the quality of famih' planning '('[\'II::e" Srwlics inFamily Planning 20( I): 1-16.

Johns Hopkins University Center for Communication Prograllb dHUCCPI..-\ID..lnd WorldHealth Organization (WHO). 1999. Do you kno\t' Yo/lr family p!a1lltil1\? chOices' [\\'allLh.u1].Baltimure.

Kim. Y. M .. et al. 2000. Self-assessment and peer review: Improving InJone"i:m ,en'iccproviders' cOImnunication with clients. Intematioflal Family Planning Per-speetin's 26! 11:-+-12.

Pariani. 5 .. Heer, D. M .. and Van Arsdol. ivl. D. 1991. Does choice make a ditkrcnce to contraceptive use? Evidence from East Java. Studies in Family Planning .2.21 () ):38-+-390,

Pyaku0'al. N .. Bhatta. G .. and Frey. ~1. No e1ale. H/\ '/,-\lDS /lrC\'Olfi(l1l (otmscling nwninl: "WIl·

lIal. Kathmandu, Nepal: Save the Children CSA.

Rinehart, \'1., Rudy,S .. and Drennan. ~l. 1998, GATHER guide to coun ...clIng. Pr1[lllldliml

Reports. series J. no. 48. Baltimore: Johns Hopkins l'ni\crsity. Population Inf<mllation PwgraIl1

Ross, L et a!. 2002. Contraceptive method choice in dewloping countries. Iltlematimllll Family

Planning Perspecti\'es 28( 1):32--l0.

Tabbutt,1. E. 1995. Strengthening commllltiClltinn skills for Homen's he£drh: .--\ training gllidt'.

Nev.; York: FeI.

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